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MALIGNANT    DISEASE    OF    THE 
LARYNX 


MALIGNANT  DISPASE 


OF 


THE    LARYNX 

{CARCINOMA    AND    SARCOMA) 


BY 

PHILIP  R.  W.   DE  SANTI,  F.R.C.S. 

SURGEON    TO    THE    THROAT.    NOSE    AND    EAR     DEPARTMENTS,    WESTMINSTER 

HOSPITAL     (late     SENIOR     ASSISTANT     SURGEON,     WESTMINSTER 

hospital)  ;    LECTURER  ON  DISEASE  OF  THE  THROAT,  NOSE, 

AND    EAR,    WESTMINSTER    HOSPITAL    IMEDICAL    SCHOOL 


NEW     YORK 

^^'  I  L  L  I  A  M     W  O  O  D     6c     COMPANY 

MDCCCCV 


PREFACE 

It  was  originally  intended  that  I  should  collaborate 
with  my  old  teacher  and  friend  Mr.  Butlin  in  re- 
editing  his  monograph  on  '  Malignant  Disease  of  the 
Larynx.'  Unfortunately,  owing  to  the  great  demands 
on  Mr.  Butlin's  time,  this  arrangement  has  been 
ri,^  found  to  be  impracticable,  and  it  has  fallen  to  my 
lot  to  publish  this  treatise  on  my  own  responsi- 
''   bility. 

C       It  is  with  gratitude  that  I  acknowledge  the  kindly 
t>    help  I  have  received  in  my  task  from  Mr.  Buthn  and 
Sir  Felix  Semon,  the  two  foremost  authorities  in  this 
^  country  on  malignant  disease  of  the  larynx, 
^v       One  of  the  main  objects  of  this  book  is  to  place 
S      before  the  profession  the  views  we  hold  in  England 
^    as  to  the  correct   operative  treatment  of  laryngeal 
,    cancer — views  which  have  not  so  far  been  sufficiently 
/  understood  or  appreciated  abroad. 
"^       If  this  treatise  should  contribute   towards  popu- 
N  larizing    the    operative   treatment    as    practised    so 
successfully    in    this    country,    I    feel     I    shall    not 
altogether  have  written  in  vain. 

15,  Stratford  Place, 

Oxford  Street,  W. 

September^  1904. 


MALIGNANT  DISEASE  OF 
THE  LARYNX 


HISTORY. 

Malignant  disease  appears  to  have  been  known  in 
the  earher  times ;  for  instance,  a  case  is  recorded  by 
Professor  Boerhave,  of  Leyden  (1668-1738),  and 
Morgagni,  of  Padua,  described  the  post-mortem 
appearances  of  a  case  of  cancer  of  the  pharynx  and 
larynx  in  a  man  of  fifty.  Later,  mention  was  made 
of  cancerous  affections  of  the  larynx,  but  it  was  not 
until  the  discovery  of  the  laryngoscope  by  Garcia  in 
1854*  that  any  great  advance  in  our  knowledge  of 
laryngeal  carcinoma  and  sarcoma,  and  of  its  accurate 
diagnosis,  became  possible. 

On  December  31,  1873,  the  first  complete  extirpa- 
tion of  the  larynx  for  cancer  was  performed  by  Bill- 
roth. Subsequently  Schrotter,  Morell  Mackenzie, 
of  London,  and  Fauvel,  of  Paris,  paid  particular 
attention  to  the  subject,  and  especially  good  work 
was    done    by    Krishaber,     Eppinger,    Cornil,    and 

■^  It  is  interesting  to  note  that  Seiior  Garcia  is  still  alive  and 
well,  and  celebrates  his  one-hundredth  b'rthday  next  year. 

I 


2      Malignant  Disease  of  the  Larynx 

Ranvier,  the  two  latter  in  pathological  anatomy.  In 
1883  a  monograph  on  '  Malignant  Disease  of  the 
Larynx,'  was  published  by  Butlin,  and  since  the  illness 
and  death  of  the  German  Emperor,  Frederick  IIL 
(1887-1888),  a  very  considerable  amount  of  clinical, 
pathological,  and  operative  work  has  been  done  in 
connection  with  these  serious  and  far  from  un- 
common affections  of  the  larynx. 

Malignant  disease  of  the  larynx  presents  itself  in 
two  forms — (i)  carcinoma,  (2)  sarcoma.  Each  will  be 
dealt  with  separately,  commencing  with  that  form 
which  is  infinitely  the  more  common,  namely, 
carcinoma. 


Carcinoma  of  the  Larynx 


CARCINOMA  OF  THE  LARYNX. 
ETIOLOGY. 

Of  the  nature  of  cancer  of  the  larynx  and  of  the 
general  causes  on  which  it  depends  nothing  more  is 
known  than  of  the  nature  and  etiolog}^  of  cancer  else- 
where, and  this  is,  when  said,  but  little  and  involved 
in  obscurity. 

Heredity  does  not  seem  to  play  any  very  marked 
role  ;  indeed,  of  born  or  inherited  predisposition  to 
cancer  of  the  larynx  the  evidence  is  distinctly 
negative,  and  curiously  different  to  the  inherited 
predisposition  noticeable  in  cancer  of  other  parts  of 
the  body,  as  of  the  breast  or  uterus.  Nevertheless, 
there  are  cases  on  record  with  a  distinct  history  of 
cancer  in  the  family.  Semon,  out  of  56  cases 
under  his  own  personal  observation,  records  3  in 
which  heredity  played  a  part.  In  i  case  the  father 
of  the  patient  suffering  from  laryngeal  carcinoma 
died  from  malignant  tumour  of  the  throat ;  in 
another  two  sisters  of  the  patient  died,  one  from 
cancer  of  the  uterus,  the  other  from  cancer  of  the 
breast ;  in  his  third  case  the  heredity  was  of  a  more 
distant  nature. 

Bailly  and  Isambert  have  recorded  a  case  in  which 
the  father  of  the  affected  patient  died  of  cancer  of 
the  pylorus  and  the  sister  of  cancer  of  the  uterus. 

Other  similar  records  exist,  and  have  been  noted 
by   Krishaber,   Baratoux,  Schmidt,   etc.,   but  whilst 

I — 2 


4       Malignant  Disease  of  the  Larynx 

admitting  that  a  family  history  of  cancer  in  persons 
suffering  from  laryngeal  cancer  occasionally  exists,  it 
has  been  of  rare  occurrence. 

Chronic  Irritation. — There  seem  to  be  fair  grounds 
for  stating  that  chronic  irritation  is  a  predisposing 
cause,  and  this  is  only  in  accordance  with  the  know- 
ledge we  have  of  chronic  irritation  producing  carci- 
noma elsewhere — for  instance,  the  lip  from  smoking, 
the  scrotum  from  soot  (chimney-sweeps). 

Excesses  in  alcohol  and  tobacco  and  overuse  of 
the  voice  have  been  considered  predisposing  causes, 
but  certainly,  as  regards  overuse  of  the  voice,  clergy- 
men, singers,  and  lawyers  do  not  seem  more  liable  to 
the  affection  than  other  people.  Nevertheless,  on 
investigation  of  the  histories  of  some  of  the  patients 
suffering  from  this  disease,  it  is  noticeable  that  they 
have  attributed  their  laryngeal  trouble  to  excessive 
use  of  the  voice,  one  man  in  particular  ascribing  his 
malady  to  loud  shouting  in  a  sawmill,  of  which  he 
was  manager. 

I  have  certainly  seen  myself  one  case  of  epithelioma 
of  the  larynx  follow  chronic  laryngitis  produced  by 
alcohol  and  abuse  of  tobacco.  In  this  case  there 
was  present  the  condition  described  by  Virchow  as 
*  pachydermia  laryngis,'  epithelioma  supervening. 

Many  of  the  patients  under  Butlin's  care  believed 
that  a  severe  cold  was  the  cause  of  the  formation  of 
tumour,  for  in  several  cases  the  first  symptoms  of 
disease  were  hoarseness  and  slight  cough.  But  it  is 
almost  certain  that  these  symptoms  of  laryngeal 
irritation  were  the  early  symptoms  of  the  tumour. 
They   did    not    pass   off  or    generally   become    less 


Carcinoma  of  the  Larynx  5 

marked  even  for  a  time,  but  in  most  instances 
persisted,  and  gradually  became  more  urgent.  A 
few  of  the  patients,  however,  appear  really  to  have 
suffered  from  a  severe  cold,  for  they  were  able  to 
assign  the  precise  date  of  its  occurrence,  and  the 
symptoms  of  the  tumour  commenced  during  the 
period  of  chronic  catarrh. 

Syphilitic  and  tubercular  lesions  of  the  larynx  are 
important  in  so  far  as  that  they  may  lead  to  carci- 
noma by  virtue  of  the  local  irritation  they  set  up. 

Lepine  and  Krishaber  have  recorded  cases  in 
which  both  tubercle  and  cancer  of  the  larynx  were 
present  in  the  same  patient. 

Semon  also  has  seen  cancer  of  the  larynx  associated 
with  tuberculosis  of  the  lungs. 

The  assertion  that  there  is  a  special  liability  to 
transformation  of  simple  benign  tumours  of  the 
larynx  into  malignant  tumours  after  repeated  endo- 
laryngeal  operations  has  been  conclusively  shown  by 
Semon's  exhaustive  collective  investigation  to  be 
unfounded. 

In  8,216  cases  of  intralaryngeal  operation  there 
were  only  5  cases  in  which  such  a  transformation 
undoubtedly  took  place,  a  proportion  of  i  in  1,645. 

In  7  further  cases  the  transformation,  although 
not  certain,  was  probable,  and  in  another  10  doubtful. 
If  these  cases  be  included  in  addition  to  the  certain 
ones,  the  proportion  of  cases  in  which  a  benign 
laryngeal  growth  underwent  malignant  degeneration 
after  endolaryngeal  operation  would  be  as  i  in  373, 
whilst  if  the  certain  and  probable  cases  only  were 
admitted,  as  i  in  685. 


6       Malignant  Disease  of  the  Larynx 

As  playing  a  very  small  part  in  the  etiology  of 
carcinoma  laryngis,  reference  may  be  made  to 
contagion  and  autoinfection.  There  are  a  few  cases 
published  bearing  on  these  two  cases,  but  the  cases 
are  so  few  that  no  more  need  be  said  on  the  subject. 

Age. — All  authors  agree  that  carcinoma  of  the 
larynx  is  most  frequently  met  with  between  the  ages 
of  40  and  70,  and  that  of  these  30  years,  the  decade 
50  to  60  is  the  one  in  which  cancer  predominates. 

In  Butlin's  monograph  the  following  table  is  given 
of  the  ages  of  50  patients  : 

Years.  Cases. 

3    -  -  -  -  -  -  I 

28  to  30  -  -  -  -  -  4 

31  to  40  -  -  -  -  -  6 

41  to  50  -  -  -  -  -  8 

51  to  60  -  -  -  -  -  15 

61  to  70  -  -  -  -  -  10 

71  to  76  -  -  -  -  -  2 

Uncertain  -  -  -  •  -  4 

Total         -  -     50 

It  will  be  seen  that  there  is  only  one  patient  under 
28  years  of  age,  and  that  patient,  strange  to  say,  was 
a  boy  of  3  years,  whose  case  is  recorded  by  Dr.  Rehn.* 
The  disease  began  with  symptoms  of  hoarseness, 
which  passed  on  to  loss  of  voice,  and  later  produced 
attacks  of  suffocation.  It  was  thought  to  have 
existed  for  at  least  two  years.  During  one  of  the 
attacks  of  suffocation  the  patient  died,  although 
tracheotomy  was  performed  for  his  relief.  Both 
cords,  the  ventricles  and  ventricular  bands,  and  the 
epiglottis,    were   the    seat   of  a  whitish-red,   warty, 

*   Virchow's  Archiv^  Bd.  xliii.,  S.  129,  1868. 


Carcinoma  of  the  Larynx  7 

cauliflower  mass,  which  appeared  to  have  originated 
in  the  ventricles.  Thus  far  the  disease  might  be 
regarded  rather  as  a  papilloma  than  an  epithelioma, 
but  the  diagnosis  rested  on  the  three  following 
circumstances  :  the  tumour  grew  almost  down  to  the 
perichondrium  of  the  thyroid  cartilage ;  the  micro- 
scopical examination  made  by  Virchow  discovered 
the  ordinary  structure  of  epithelioma,  with  solid 
plugs  of  epithelium  dipping  down  into  the  muscles 
and  other  deeply-seated  tissues  ;  and  there  was  one 
enlarged  lymphatic  gland  at  the  inner  border  of  the 
sterno-mastoid  muscle.  In  the  face  of  these  condi- 
tions the  disease  can  scarcely  be  considered  other 
than  epithelioma  occurring  at  a  marvellously  early 
age.  With  this  exception  the  table  of  ages  corre- 
sponds with  that  of  epithelioma  of  the  tongue,  the 
lip,  and  other  parts,  save  that  the  number  of  cases 
between  28  and  30  is  unusually  large. 

Dufour  has  recorded  a  case  in  a  still  younger 
patient,  a  child  of  i  year  of  age. 

Sendziak's  table  of  486  cases  of  cancer  of  the 
larynx  collected  from  various  sources  gives  the 
following  results  : 


Years. 

Cases. 

Between 

I  and  20 

- 

- 

5 

20  and  30 

- 

- 

22 

30  and  40 

- 

- 

41 

40  and  50 

- 

- 

121 

50  and  60 

- 

- 

188 

60  and  70 

- 

- 

80 

70  and  80 

- 

- 

17 

80  and  90 

- 

- 

5 

Cases 

in 

which  the  ; 

age 

was 

not 

stated  - 

7 

Total         -  -     486 


8       Malignant  Disease  of  the  Larynx 

Between  the  ages  of  40  to  70  there  were,  therefore, 
389  cases,  more  than  84  per  cent,  of  the  whole 
number.  These  results  agree  with  those  of  Semon. 
He  gives  103  cases,  87  of  which  occurred  between 
the  ages  of  40  to  70,  again  more  than  84  per  cent. 

The  tables  of  Baratoux  and  others  support  these 
results. 

The  age  of  the  oldest  patient  in  which  cancer  of 
the  larynx  has  been  recorded  is  83  (Semon),  and 
next  to  this  patient  a  man  of  82  (Preisendorffer). 

Sex. — The  much  greater  liability  of  males  than 
females  to  cancer  of  the  larynx  has  been  noticed  by 
most  writers.  Of  the  50  patients  already  referred  to, 
40  were  males  and  10  were  females.  Out  of  Send- 
ziak's  486  cases,  400  were  males,  68  females,  and  in 
18  there  is  no  mention  of  the  sex. 

Schwartz  noted  153  males  and  26  females.  Bara- 
toux's  statistics  give  265  males  and  only  36  females. 
Semon  notes  79  males  and  24  females.  Jurasz  in 
21  cases  of  cancer  of  the  larjmx  mentions  only  i  as 
being  of  the  female  sex. 

There  seem  to  be  no  satisfactor}^  reasons  to  explain 
the  differences  in  the  liability  of  the  sexes  to  carci- 
noma of  the  larynx.  In  dealing  with  the  occupations 
and  habits  of  the  patients  as  etiological  factors,  it  has 
been  pointed  out  that  there  is  nothing  which  leads 
one  to  suppose  that  either  occupation  or  habit  pre- 
disposed to  the  disease  in  any  appreciable  number  of 
cases. 

Fauvel  has  suggested  that  the  larynx  is  much 
more  liable  to  innocent  and  malignant  tumours  in 
men    than    women    because   these   diseases   find   in 


Carcinoma  of  the  Larynx  9 

women  a  soil,  as  it  were,  prepared  for  them  in  the 
breasts  and  uterus  ('  Physiological  Activity  and 
Decline  'j. 

Schiffers*  has  gone  further  than  Fauvel  by  suppos- 
ing that  cancer  plays  in  the  larynx  in  the  male  the 
role  which  it  plays  in  the  uterus  in  the  female.  He 
speaks  of  the  sympathy  which  exists  between  the 
larynx  and  the  uterus  at  puberty,  and  of  their 
reciprocal  influence. 

Dr.  Schiffers  seems  to  be  unaware  of  the  fact  that 
the  lower  lip,  the  tongue,  and  the  oesophagus  are  all 
more  frequently  attacked  by  cancer  in  men  than 
women,  and  that  the  disproportion  is  greatest  in 
cancer  of  the  lower  lip. 

It  is  also  a  curious  fact  that  in  women  the 
extrinsic  form,  in  men  the  intrinsic,  is  much  more 
common. 

PATHOLOGICAL  ANATOMY. 

In  considering  both  sarcoma  and  carcinoma  of  the 
larynx,  the  division  suggested  by  Krishaber  into 
tumours  of  intrinsic  and  extrinsic  origin  has  been 
hitherto  that  most  universally  adopted,  for  it  appears 
to  be  not  merely  convenient  for  purposes  of  classifi- 
cation, but  is  considered  valuable  in  relation  to  the 
subject  of  secondary  infection  of  the  lymphatic  glands. 

The  term  intrinsic  is  applied  to  tumours  which 
arise  in  connection  with  the  vocal  cords,  the  ven- 
tricles, the  false  vocal  cords,  and  the  parts  immediately 
below  the  true  vocal  cords  ;    the   term   extrinsic   to 

*  Rev.  Meiis.  de  Laryng..,  vol.  iv.,  p.  i6,  1883. 


lo     Malignant  Disease  of  the  Larynx 

those  tumours  which  grow  from  the  epiglottis,  the 
aryepiglottic  folds,  the  interarytenoid  folds,  etc. 

The  question  of  the  affection  of  the  lymphatic 
glands  is  one  whose  importance  it  is  difficult  to 
overestimate.  In  1879*  Krishaber  laid  down  the 
general  rule  that  the  extrinsic  cancers  affect  the 
glands  at  an  early  period,  and  that  the  intrinsic 
cancers,  so  long  as  they  are  limited  to  the  cavity  of 
the  larynx,  do  not  affect  the  glands. 

Schwartz  uses  the  terms  '  cavitaires  et  marginaux ' 
(of  the  interior,  and  of  the  borders  of  the  larynx). 
Recently  Cuneot  suggested  the  abandonment  of 
Krishaber's  division  into  intrinsic  and  extrinsic 
carcinomas,  and  the  substitution  of  a  division  into 
supraglottic,  infraglottic,  and  glottic  carcinomas, 
basing  this  division  on  his  anatomical  researches 
of  the  laryngeal  lymphatic  system. 

In  my  opinion,  no  sufficient  grounds  have  been 
adduced  for  abandoning  Krishaber's  classification, 
which  in  the  main,  as  regards  infection  of  the  glands, 
remains  true  to  the  present  time. 

The  following  account  of  the  lymphatic  system  is 
important  in  relation  to  the  almost  universal  adoption 
of  Krishaber's  classification  and  the  deductions  made 
by  him  as  to  secondary  lymphatic  infection. 

Lymphatics  of  the  Larynx. 

Apparently  the  first  accurate  description  of  the 
laryngeal  lymphatics  was  published  by  Teichmann, 

*  Krishaber,  '  Annales  de  Laryngol.,'  1879. 
t  Gazette  dcs  Hopihiiix^  No.  141,  1902. 


Carcinoma  of  the  Larynx  i  i 

who  laid  particular  stress  on  the  distribution  of  the 
terminal  vessels  in  the  mucous  membrane  of  the 
larynx.  In  1871  Luschka  published  his  excellent 
work  on  the  lymphatic  system,  and  in  1874  Sappey* 
completed  the  description  of  these  vessels,  and  gave 
an  account  of  the  general  arrangement  of  the  lym- 
phatic radicles  and  their  final  distribution  to  the 
lymphatic  glands.  In  i887t  Poirier  injected  the 
lymphatics  of  the  inferior  true  vocal  cords,  the 
existence  of  which  had  up  till  then  been  contested, 
and  drew  attention  again  to  the  pre-laryngeal  glands 
referred  to  by  Engel  in  1859,  but  which  had  not 
been  recognised  by  writers  since. 

In  1899+  Most  investigated  the  laryngeal  lym- 
phatics, and  for  his  investigation  employed  the 
method  of  Gerota,  and  recently§  Cuneo  published 
an  article  giving  his  results  obtained  by  injecting 
several  larynges  in  the  same  m^anner  as  Most,  and 
corroborating  Most's  results.  I  have  also  employed 
Gerota's  method,  and  find  the  results  agree  in  the 
main  with  Cuneo's. 

The  following  account  of  the  lymphatic  laryngeal 
system  is  as  given  by  Cuneo,  and  confirmed  by  my 
own  injections,  except  where  specifically  found  to 
differ. 

*  '  Anatomie,  Physiologic,  Pathologic  dcs  Vaisseaux  Lym- 
phatiqucs.'     Paris,  1874. 

t  '  Vaisseaux  Lymphatiqucs  du  Larynx  :  GangHon  Pre- 
laryngd,'  Progres  Med.,  1887,  No.  19,  p.  373. 

±  Anat.  Ans.^  1899,  p.  387,  and  Zeitschr.  f.  Chir.,  Bd.  Ivii., 
1900, 

§  Gazette  des  Hopitaitr,  No.  141,  1902. 


12     Malignant  Disease  of  the  Larynx 

The  Lymphatic  Radicles. — The  lymphatics  of  the 
larynx  take  their  origin  in  a  network  that  covers  the 
whole  of  the  internal  surface  of  the  larynx,  and  is 
densest  where  the  mucous  membrane  is  thickest, 
but  divisible  into  two  areas,  an  upper  and  a  lower 
area. 

The  upper  area  in  which  the  terminal  network  is 
in  greater  part  very  dense,  and  quite  easy  to  inject, 
includes  all  the  portion  of  the  laryngeal  mucous 
membrane  above  the  glottis,  namely  the  epiglottis, 
aryteno-epiglottidean  folds,  superior  vocal  cords, 
and  the  ventricles. 

The  inferior  area  includes  the  mucous  membrane 
of  the  larynx  below  the  glottis.  At  this  level  the 
network  is  decidedly  less  dense,  and  in  all  cases  less 
easy  to  inject  than  that  of  the  upper  area. 

These  two  areas  are  relatively  independent  of  one 
another.  They  are,  as  a  matter  of  fact,  separated  by 
an  intermediary  zone,  formed  by  the  inferior  vocal 
cords,  at  which  level  the  lymphatic  radicles  are 
even  more  rare  and  attenuated,  though  not  entirely 
absent. 

At  the  level  of  the  posterior  aspect  of  the  larynx 
the  two  areas  extend  without  any  very  clear  line  of 
demarcation.  If  an  injection  at  the  level  of  the 
inferior  vocal  cord  be  pushed,  the  material  injected 
usually  enters,  according  to  Most,  the  vessels  of  the 
upper  area. 

It  is  of  importance  to  note  that  the  lymphatics  of 
one  half  of  the  larynx  do  not  communicate  with 
those  of  the  opposite  side  anteriorly,  but  that  at  the 
level  of  the  posterior  median  line  the  intercommuni- 


Carcinoma  of  the  Larynx  13 

cations  are  very  numerous.  The  network  of  the 
lower  area  is  directly  continuous  with  the  tracheal 
network,  there  being  no  line  of  demarcation  at  all. 
Similarly  the  network  of  the  upper  area  is  directly 
continuous  with  the  network  covering  the  mucous 
membrane  of  the  pharynx  and  base  of  the  tongue. 

All  these  facts  are  of  great  importance  from  the 
point  of  view  of  the  local  spread  of  laryngeal  cancer. 

Distribution  of  the  Lymphatic  Channels   arising 
from  the  Lymphatic  Radicles. 

Each  of  the  two  areas  have  a  distinct  set  of  efferent 
vessels. 

The  trunks  arising  from  the  upper  meshwork 
run  towards  the  lateral  parts  of  the  epiglottis  and 
aryepiglottic  folds,  and  then  pierce  the  thyro-hyoid 
membrane  at  the  point  of  entry  of  the  superior 
laryngeal  artery. 

After  piercing  the  thyro-hyoid  membrane,  these 
collecting  trunks  divide  into  three  sets,  an  ascending 
group  of  one  or  two  in  number,  which  cross  the 
hypoglossal  nerve  and  end  in  a  gland  situated  just 
below  the  posterior  belly  of  the  digastric  muscle,  a 
horizontal  group  emptying  into  the  glands  placed  on 
the  internal  jugular  vein  at  the  level  of  the  bifurca- 
tion of  the  common  carotid,  and  a  descending  group 
ending  in  glands  of  the  same  chain  at  a  level  of  the 
middle  part  of  the  lateral  lobes  of  the  thyroid  gland. 

Occasionally  one  or  two  small  glands  are  found  on 
the  thyro-hyoid  membrane  itself,  but  they  do  not, 
when   present,  receive  lymphatics  from  the  larynx ; 


14     Malignant  Disease  of  the  Larynx 

their  lymphatics  come  from  the  lateral  regions  of  the 
pharynx. 
The  trunks  arising  from   the  lower  meshwork 

are  divisable  into  two  groups,  one  anterior,  the  other 
posterior. 

The  anterior  group  (supracricoid)  consists  of 
three  or  four  trunks,  which  perforate  the  crico-thyroid 
membrane  near  the  middle  line.  Some  of  these 
trunks  end  in  the  pre-laryngeal  glands  (Poirier), 
others  in  a  pre-tracheal  gland  (Most),  and  others  in 
one  of  the  glands  of  the  middle  or  inferior  sterno- 
mastoid  chain  of  glands. 

The  pre-laryngeal  and  pre-tracheal  glands  form 
(Poirier-Charpy,  t.  xi.,  p.  1280)  part  of  a  chain 
described  as  the  deep  cervical  chain. 

This  chain  consists,  according  to  Poirier,  of  three 
distinct  groups  or  masses  of  glands. 

(i)  A  pre-laryngeal  mass,  first  noted  by  Engel. 
Its  existence  has  been  confirmed  by  Poirier,  he 
finding  the  pre-laryngeal  group  present  49  times  out 
of  100.  Usually  only  one  gland  is  present,  which  in 
the  adult  is  about  the  size  of  a  pea,  and  tends  to 
atrophy  in  old  age.  It  is  generally  found  in  the 
middle  of  the  V-shaped  space  formed  by  the  two 
crico-thyroid  muscles,  although  occasionally  it  is 
overlapped  by  the  inner  border  of  one  of  these 
muscles. 

In  I  out  of  6  cases  a  second  gland  about  the  size 
of  a  pin's  head  has  been  found  at  the  level  of  the  top 
of  the  V-shaped  space. 

Sometimes  a  gland  has  been  found  on  the  upper 
edge  of  the  isthmus  of  the  thyroid  (Mascagni,  Rou- 


Carcinoma  of  the  Larynx  15 

baud,  Most),  and  occasionally  a  gland  in  front  of  the 
thyroid  cartilage  close  to  its  anterior  border. 

(2)  A  pre4hyroidean  mass,  placed  in  front  of  the 
isthmus  of  the  thyroid.  This  group  is  only  rarely 
present. 

(3)  A  pre-tracheal  mass,  usually  consisting  of 
one  gland  of  the  size  of  a  small  pea,  and  situated 
about  i|  centimetres  above  the  sternal  notch. 

There  may,  however,  be  more  than  one  pre-tracheal 
gland.  The  afferent  vessels  of  the  pre-laryngeal 
glands  are  some  of  the  lymphatics  of  the  middle 
lymphatic  pedicle  of  the  larynx  and  those  of  the  pre- 
tracheal come  partly  from  the  thyroid  body,  parti}- 
from  the  pre-laryngeal  glands. 

The  efferent  vessels  from  the  pre-laryngeal,  pre- 
thyroidean,  and  pre-tracheal  glands  empty  themselves 
into  the  lowermost  glands  of  the  sterno-mastoid 
chain. 

The  posterior  or  infracricoid  group  consists  of 
three  to  five  trunks,  which  pass  over  the  crico-tracheal 
membrane  at  the  junction  of  the  lateral  and  posterior 
aspects  of  the  trachea. 

These  trunks  end  in  two  to  five  glands  running 
parallel  with  the  recurrent  laryngeal  nerve.  These 
glands  collect  vessels  from  the  thyroid  body,  the 
lymphatics  of  the  inferior  pedicle  of  the  larynx,  and 
the  vessels  from  the  cervical  portion  of  the  trachea 
and  oesophagus. 

Their  efferent  vessels  end  in  the  lowermost  glands 
of  the  sterno-mastoid  chain  and  the  supraclavicular 
glands.  To  sum  up,  the  lymphatic  channels  emanat- 
ing from  the  larynx  empty  themselves  into  the  glands 


i6     Malignant  Disease  of  the  Larynx 

situated  beneath  the  sterno-mastoid  muscles  into  the 
pre-larj-ngo-tracheal  glands  and  into  the  glands 
accompanying  the  recurrent  laryngeal  nerves,  and 
additionally  into  the  supra  clavicularglands. 

The  group  of  glands  underneath  the  sterno- 
mastoid  muscles  must  be  looked  upon  as  the 
principal  group  of  glands  to  finally  receive  the 
lymphatics  of  the  larynx.  The  pre-laryngeal,  pre- 
tracheal, and  recurrent  groups  are  only  simple 
glandular  points  placed  as  interrupters  on  the  line  of 
the  lymphatic  vessels  going  from  the  subglottic 
area  to  the  deeper  group  of  sterno-mastoid  glands 
(Cuneo). 

Application  of  these  Anatomical  Facts  to  the 
Extension  of  Epithelioma  of  the  Larynx  by 
the  Lymphatics. 

Extrinsic  carcinoma  includes  several  varieties — 
cancer  of  the  epiglottis  (very  frequent),  of  the  ary- 
epiglottic  folds  (less  frequent),  and  of  the  arytenoid 
region  (rare). 

These  differently  -  placed  carcinomas  all  present 
common  characteristics.  They  tend  to  push  them- 
selves towards  the  upper  opening  of  the  larynx,  and 
to  invade  the  lateral  regions  of  the  larynx  and 
pharynx. 

Whilst  extrinsic  carcinoma  reaches  the  final  stage 
of  its  evolution  by  invading  the  extra-laryngeal  parts, 
it  is  at  the  level  of  the  posterior  aspect  of  the  thyro- 
hyoid membrane  that  these  extensions  are  liable  to 
become  visible,  namely,  to  ulcerate  through. 


Carcinoma  of  the  Larynx  17 

Extrinsic  carcinoma  in  its  downward  growth  tends 
to  become  arrested  at  the  level  of  the  inferior  vocal 
cords.  This  has  been  noted  by  several  observers, 
yet,  at  the  same  time,  it  must  not  be  understood 
that  the  inferior  vocal  cords  form  an  absolutely  im- 
passable barrier,  only  that  they  seem,  at  all  events,  to 
arrest  its  extension  for  some  length  of  time. 

Intrinsic  carcinoma  includes  cancer  affecting  the 
superior  false  vocal  cords,  the  ventricles,  the  true 
vocal  cords,  and  the  parts  immediately  below  the 
true  vocal  cords  (subglottic  region).  The  true  vocal 
cords  are  most  frequently  the  initial  seat  of  laryngeal 
carcinoma,  although  some  observers  are  of  opinion 
that  the  false  vocal  cords  are  most  frequently  affected. 
The  statistics  of  Sendziak  show  the  true  vocal  cords 
to  have  been  the  seat  of  disease  in  107  cases,  whereas 
the  false  vocal  cords  were  affected  in  only  27.  Semon, 
again,  out  of  55  cases,  notes  the  true  vocal  cords  as 
affected  in  15  cases  and  the  false  in  3  only.  On  the 
other  hand,  Baratoux,  out  of  117  cases,  noted  62  that 
were  primary  in  the  false  vocal  cords  against  29  in 
the  true  vocal  cords,  and  Fauvel,  out  of  '^^  cases, 
records  only  i  in  which  the  true  vocal  cords  were 
the  primary  seat  of  disease. 

Carcinoma  of  the  true  or  false  vocal  cords  is  con- 
spicuous by  virtue  of  the  slowness  of  its  evolution, 
particularly  so  when  the  true  vocal  cord  is  the  initial 
seat  of  disease. 

According  to  some  authorities,  carcinoma  of  the 
true  vocal  cord  has  a  tendency  to  extend  at  first 
towards  the  opposite  cord,  then  towards  the  supra- 
glottic   region.     It   is,   however,  in  the    majority  of 

2 


1 8     Malignant  Disease  of  the  Larynx 

cases  impossible  to  tell  in  what  direction  the  growth 
will  spread,  cases  being  very  dissimilar  in  this  respect. 
At  the  same  time,  in  my  experience  there  is  a 
tendency  for  carcinoma  attacking  the  true  or  false 
vocal  cords  to  spread  towards  the  supraglottic 
region. 

Subglottic  carcinoma  is  rare.  Out  of  486  cases  of 
laryngeal  cancer,  Sendziak  only  collected  5.  Out  of 
50  cases  collected  by  Butlin  in  his  monograph  on 
*  Malignant  Disease  of  the  Larynx,'  5  were  infra- 
glottic,  in  every  case  situated  immediately  below  the 
vocal  cord.  A  case  of  this  kind  was  published  in  the 
NeiiJ  York  Medical  Record  by  Dr.  Delavan,*  who 
regarded  the  situation  of  the  tumour  as  unique.  But 
a  similar  case  is  recorded  by  Emile  Blanc, t  a  third 
case  by  Krishaber,t  and  a  fourth  by  Norton. §  The 
close  resemblance  of  this  case  to  that  recorded  by 
Dr.  Delavan  is  very  striking.  In  neither  was  there  a 
visible  tumour ;  in  both  the  vocal  cord  was  paralyzed 
and  a  little  thrust  up  by  the  tumour.  In  neither  was 
there  any  affection  of  the  glands  or  of  any  of  the 
other  organs  or  tissues.  In  Blanc's  case  the  tumour 
was  visible  between  the  vocal  cords,  and  the  tumour 
could  also  be  seen  in  Krishaber's  case. 

The  fifth  of  the  series  occurred  in  St.  Bartholo- 
mew's Hospital  in  a  man  fifty-six  years  old,  who  had 
suffered  from  laryngeal  trouble,  slight  hoarseness 
and   cough,    with    severe   attacks   of    dyspnoea,    for 

*  New  York  Medical  Record,  vol.  xx.,  p.  625,  1881. 

t  Loc.  cit.,  p.  46,  obs.  2. 

X  Gaz.  Hebdo7n.^  p.  540,  1879. 

§  Path.  Trails.^  vol.  xxiii.,  p.  43,  1872. 


Carcinoma  of  the  Larynx  19 

several  months.  One  of  the  vocal  cords  was  observed 
to  be  paralyzed,  but  no  tumour  could  be  discovered. 
His  symptoms  were  ascribed  to  various  causes,  among 
others  to  aneurism  of  the  aorta,  and  to  affection  of 
the  recurrent  laryngeal  nerve ;  and  it  was  not  until 
after  his  death,  which  took  place  from  apnoea,  that 
the  real  nature  of  the  malady  was  made  apparent. 

A  tumour  the  size  of  a  hazel-nut  lay  immediately 
below  the  right  vocal  cord,  partly  embedded  in  the 
wall  of  the  larynx.  It  had  perforated  the  alae  of  the 
thyroid  cartilage,  and  produced  a  very  small  col- 
lection of  matter  on  the  outer  surface  of  the  larynx. 
The  swelling  had  not  been  perceptible  through  the 
tissues  over  the  thyroid  cartilage,  nor  was  there  any 
enlargement  of  the  lymphatic  glands  from  which  a 
clue  to  the  nature  of  the  disease  might  have  been 
derived.  The  tumour  was  an  admirable  specimen  of 
squamous-celled  carcinoma. 

Subglottic  carcinomas  tend  to  invade  the  trachea, 
and  have  been  noticed  to  become  arrested  in  their 
growth  for  a  time  when  reaching  the  level  of  the 
inferior  true  vocal  cords.  In  a  case  observed  by 
Cuneo,  the  true  vocal  cords  were  invaded,  but  the 
supraglottic  area  was  quite  free. 

Whatever  may  be  the  original  site  of  origin  of  a 
laryngeal  carcinoma,  it  tends  to  remain  limited  at  its 
commencement  to  one -half  of  the  larynx;  only 
carcinoma  of  the  epiglottis  and  of  the  arytenoid 
region  are  exceptions  to  this  rule.  This  limitation 
is  of  considerable  importance  in  connection  with 
operative  interference.  It  often  permits  of  a  partial 
instead  of  a  total  laryngectomy,  with  a  smaller  death- 

2 — 2 


20    Malignant  Disease  of  the  Larynx 

rate  and  a  better  chance  of  restitution  of  the  functions 
of  the  organ. 

This  Hmitation  to  one-half  is,  however,  merely 
temporary ;  sooner  or  later  the  neoplasm  tends  to 
attack  the  opposite  side.  In  a  few  cases  the  opposite 
side  has  become  affected  by  contact,  but  usually  it 
is  by  direct  continuous  invasion.  This  most  often 
occurs  at  the  level  of  the  posterior  aspect  of  the 
larynx,  although  it  has  been  observed  to  invade  the 
opposite  cord  through  the  anterior  commissure 
(B.  Fraenkel,  Semon). 

To  sum  up,  extrinsic  carcinomas  tend  to  grow 
towards  the  superior  orifice  of  the  larynx,  and  often 
cease  to  extend  when  they  reach  the  level  of  the 
glottis.  Intrinsic  carcinomas,  if  above  the  glottis, 
also  tend  to  spread  towards  the  superior  orifice  of 
the  larynx,  but  remain  localized  much  longer  than 
extrinsic  carcinomas,  especially  so  when  the  true 
vocal  cords  are  primarily  attacked ;  if  below  the 
glottis,  they  tend  to  spread  towards  the  trachea. 

Finally,  with  the  exception  of  cancers  of  the 
epiglottis  and  arytenoid  region,  laryngeal  cancers 
remain  localized  for  a  period  more  or  less  long. 
These  rules  are  by  no  means  absolute ;  there  are 
many  exceptions;  still,  they  are  applicable  to  the 
majority  of  cases. 

It  is  easy  to  see  that  the  distribution  of  the 
lymphatics  can  to  a  great  extent  explain  these 
different  particulars  in  the  local  extension  of  malig- 
nant disease  of  the  larynx. 

The  arrest  for  a  long  time  of  growths  reaching  to 
the  inferior  vocal  cords  is  the  result  of  the  attenua- 


Carcinoma  of  the  Larynx  21 

tion  and  diminution  in  number  of  the  lymphatics  at 
this  point. 

In  extending  towards  the  superior  laryngeal  orifice, 
extrinsic  epitheliomas  only  obey  the  general  law 
observable  in  the  extension  of  all  epitheliomas — 
namely,  a  preference  to  follow  the  course  of  the 
lymphatic  current. 

Extension  of  epithelioma  of  the  epiglottis  to  the 
base  of  the  tongue  finds  an  easy  explanation  in  the 
connection  of  the  lingual  lymphatic  vessels  with 
those  originating  from  the  anterior  surface  of  the 
epiglottis. 

Moreover,  the  continuity  of  the  subglottic  mesh- 
work  with  that  of  the  trachea  gives  the  clue  to  the 
relative  facility  with  which  subglottic  epithelioma 
descends  towards  the  trachea.  The  paucity  in 
number  of  the  lymphatics,  although  slight  as  regards 
the  superior  vocal  cords,  but  very  marked  at  the 
level  of  the  inferior  vocal  cords,  is  certainly  one 
of  the  factors  determining  the  slow  evolution  of 
epithelioma  developing  in  these  regions.  Another 
factor  worthy  of  note,  in  my  opinion,  is  the  tendency 
to  atrophy  of  these  lymphatic  radicles  as  old  age 
approaches.  It  is  certainly  increasingly  difficult  to 
make  a  thorough  injection  of  the  laryngeal  lymphatics 
the  older  the  patient  on  whom  the  injection  is 
practised;  in  very  young  children  an  injection  is 
much  more  easy  to  make  and  extensive  in  nature. 

Finally,  the  abstention  of  involvement  of  the 
opposite  side  of  the  larynx  for  a  more  or  less  lengthy 
period  is  due  to  the  relative  independence  of  the 
lymphatics  of  each  half  of  the  larynx. 


2  2    Malignant  Disease  of  the  Larynx 

Like  all  epitheliomas,  cancer  of  the  larynx  tends 
eventually  to  invade  the  lymphatic  glands.  This 
implication  is  the  rule  in  late  cases ;  it  is  generally 
particularly  well  marked  in  those  cases  in  which  a 
palliative  tracheotomy  has  been  performed,  and  in 
which  the  disease  is  too  extensive  for  operative  inter- 
ference. 

It  is  decidedly  rare  to  find  cases  in  which  the 
whole  of  the  interior  of  the  larynx  has  been  destroyed 
by  epithelioma  without  there  being  the  slightest 
glandular  infection.  A  good  example  of  such  a  case, 
however,  is  given  by  Most. 

Glandular  infection  is,  however,  undoubtedly  rare 
if  the  growth  be  of  intrinsic  origin  and  limited  in 
size,  especially  so  if  attacking  the  anterior  two-thirds 
of  the  true  vocal  cords. 

Schleier*  has  noted  it  20  times  only  out  of  125 
cases  ;  Sendziak,  54  out  of  486  cases.  Other  authors, 
however,  give  a  much  higher  percentage.  Jurasz,t 
9  out  of  21  cases;  Schwartz,  13  out  of  28.  All  these 
statistics  have  only  a  relative  value  ;  they  are,  as 
Cuneo  points  out,  based  on  clinical  observations, 
which  are  often  fallacious.  Absence  of  enlarged 
glands  to  palpation  does  not  prove  their  being  free 
from  infection.  Madelung,  Salzer,t  etc.,  have  found 
cancerous  cells  in  glands  which  had  retained  their 
normal  size  and  appearance. 

Again,  glandular  enlargement  in  a  case  of  laryngeal 
carcinoma    does    not    necessarily    mean    malignant 


*  Deuts.  Med.  Wochens..,  \\ 

t  Heymann's  '  Handbuch,'  vol.  i.,  p.  885. 

\  Salzer,  Arch.f.  Kli?i.  Chir.,  1885,  Bd.  xxxi. 


Carcinoma  of  the  Larynx  23 

infection.  Such  enlargement  may  be  due  to  septic 
infection  from  a  septic  cancerous  ulcer,  or  be  inde- 
pendent of  the  cancer  and  due  to  some  simple  septic 
lesion  of  the  tonsils  or  pharynx. 

Satisfactory  statistics  as  to  glandular  infection  can 
only  really  be  arrived  at  by  thorough  microscopic 
examination  of  the  glands  in  each  and  every  case 
removed  at  the  same  time  as  the  laryngeal  cancer, 
both  ante-  and  post-mortem.  Nevertheless,  the 
broad  clinical  fact  remains  that  in  certain  cases  of 
laryngeal  carcinoma  involvement  of  the  glands  is 
certain  and  early,  in  others  uncertain  and  late. 

Several  causes,  according  to  Cuneo,  have  been 
brought  forward  to  explain  the  early  immunity  of 
the  glands. 

First  of  all,  the  major  number  of  laryngeal  cancers 
are  squamous-celled  epitheliomata  (248  out  of  486 
cases,  Sendziak),  and  it  is  stated  by  Cuneo  that  this 
variety  of  growth  generally  attacks  the  glands  some- 
what late.  This,  however,  cannot  be  held  to  be 
correct,  for  in  epithelioma  attacking  the  tongue  or 
tonsil  very  early  and  extensive  implication  of  the 
glands  is  the  rule. 

Secondly,  the  same  authority  holds  the  opinion 
that  cancer  of  the  larynx  tends  frequently  to  become 
pedunculated,  and  to  grow  into  the  cavity  of  the 
larynx  without  extending  much  beyond  the  border 
of  its  base  of  origin,  and  that  these  pedunculated 
cancers  growing  into  a  cavity  do  not  as  a  rule  invade 
the  glands  until  a  very  late  stage,  a  good  example 
being  papillary  carcinoma  of  the  bladder. 

Whilst  admitting  that  a  laryngeal  carcinoma  may 


24    Malignant  Disease  of  the  Larynx 

become  pedunculated,  such  an  occurrence  is  decidedly 
uncommon  ;  the  general  rule  is  to  find  a  sessile 
growth  with  early  infiltration  of  the  parts  at  its  base 
of  origin. 

Finally,  if  certain  parts  of  the  larynx,  such  as  the 
aryteno-epiglottidean  folds  and  epiglottis,  are  very 
rich  in  lymphatics,  it  is  seen  that  in  other  parts,  such 
as  the  subglottic  area,  the  lymphatic  meshwork  is 
much  less  developed,  and  that  on  the  true  vocal 
cords,  one  of  the  sites  of  election  for  epithelioma, 
the  lymphatics  are  so  few  in  number  that  their 
injection  is  a  matter  of  considerable  difficulty. 

Is  it  not  probable  that  the  more  or  less  tardy 
appearance  of  glandular  infection  is  intimately 
connected  with  the  site  of  origin  of  a  laryngeal 
cancer  ? 

'  As  long  as  the  cancer  remains  intrinsic,'  says 
Krishaber,  *  there  is  no  cervical  glandular  enlarge- 
ment ;  when  it  is  extrinsic  the  glands  are  infected.' 

This  statement,  although  too  absolute,  is  borne 
out  by  general  experience. 

Cuneo  considers  Krishaber's  classification  incon- 
venient, in  that  it  includes  under  the  same  heading 
varieties  behaving,  as  regards  glandular  infection,  in 
very  different  ways.  Cuneo  states  :  '  One  would 
have  to  admit  that  epitheliomas  attacking  the 
superior  vocal  cords,  which  are  rich  in  lymphatics, 
involve  the  glands  equally  late  as  in  epithelioma 
attacking  the  inferior  vocal  cords,  the  lymphatics  of 
which  are  extremely  few  and  ill -developed.'  He 
goes  on  to  state  that  he  has  seen  and  collected  other 
cases  showing  that  glandular  infection  occurs  early 


Carcinoma  of  the  Larynx  25 

when  the  superior  vocal  cords  are  the  site  of  origin 
of  laryngeal  cancer. 

In  describing  the  anatomy  of  the  laryngeal  lym- 
phatics, I  have  stated  that,  in  the  main,  the  results 
of  my  injections  were  identical  with  those  of  Cuneo  ; 
yet,  as  regards  the  richness  of  the  lymphatic  network 
in  the  region  of  the  superior  vocal  cords,  I  did  not 
find  myself  in  agreement  with  him.  I  found  there 
was  a  distinct  tendency  in  a  supraglottic  injection 
for  the  lymphatic  system,  as  it  invaded  the  superior 
vocal  cords,  to  become  altered ;  though  the  lym- 
phatic radicles  traversed  the  superior  cords,  still,  they 
were  found  to  become  more  and  more  attenuated  as 
they  reached  their  free  border.  In  fact,  the  region 
of  the  superior  vocal  cords  was  distinctly  less  rich  in 
lymphatics  than  the  parts  above,  although  richer 
than  in  the  region  of  the  inferior  vocal  cords. 
Again,  those  English  laryngologists  who  have  had 
most  experience  of  malignant  disease  of  the  larynx 
do  not  agree  with  Cuneo's  statement  that  glandular 
infection  occurs  early  in  cancer  attacking  the  superior 
vocal  cords;  on  the  contrary,  glandular  infection  is 
met  with  in  such  cases  as  a  rule  at  a  late  stage, 
usually  when  the  disease  has  spread  to  the  extrinsic 
parts  of  the  larynx. 

In  my  opinion,  the  immunity  of  the  glands  to 
secondary  infection  depends  mainly  on  the  original 
site  of  origin  of  the  malignant  growth.  If  intrinsic, 
glandular  infection  is  rare  and  only  occurs  late ;  if 
extrinsic,  it  is  the  rule,  and  occurs  early.  This 
difference  in  the  tendency  to  implication  of  the 
neighbouring  glands  according  to  whether  the  disease 


26    Malignant  Disease  of  the  Larynx 

is  of  intrinsic  or  extrinsic  origin  is  due,  in  my  opinion, 
to  the  distribution  of  the  lymphatics  already  de- 
scribed in  these  two  areas. 

It  has  been  amply  demonstrated  that  the  lym- 
phatic meshwork  is  much  less  dense  in  the  area 
described  as  intrinsic  than  in  the  extrinsic  area,  and 
it  is  to  this  diminution  and  attenuation  of  the  lym- 
phatic radicles  in  the  intrinsic  parts  that  the  marked 
immunity  to  early  glandular  infection  must  be 
ascribed. 

A  secondary  factor,  as  has  already  been  pointed 
out,  probably  exists  in  the  tendency  to  progressive 
atrophy,  normally  found,  of  the  lymphatic  system  in 
the  larynges  of  old  people,  and  this  attenuation  and 
atrophy  not  only  applies  to  the  laryngeal  mucous 
membrane,  but  also  to  the  lymphatic  ducts  that  go 
to  the  neighbouring  glands. 

Topography  of  the  Glands  attacked  by  Laryngeal 

Carcinoma. 

Bearing  in  mind  the  anatomical  description  already 
given,  one  finds  that  theoretically  the  chain  of  glands 
underneath  the  sterno- mastoid,  the  pre -laryngo- 
tracheal, and  the  recurrent  laryngeal  group  of  glands 
should  show  signs  of  infection.  Special  stress  has 
already  been  laid  on  the  infection  of  the  substerno- 
mastoid  chain  ;  all  the  glands  included  between  the 
posterior  belly  of  the  digastric  muscle  and  the 
clavicle  may  become  infected  in  cases  of  malignant 
disease  of  the  larynx.  There  is  nothing  especially 
characteristic  in  their  mode  of  invasion.     Infected 


Carcinoma  of  the  Larynx  27 

and  broken-down  glands  are  frequently  found  ad- 
herent to  the  vasculo- nervous  sheaths;  they  are 
usually  independent  of  the  larynx  itself,  although 
in  some  cases  they  have  been  found  to  be  incor- 
porated with  that  organ. 

Cuneo  has  seen  a  case  in  w^hich  there  was  a  direct 
extension  of  the  growth  formed  by  a  much-thickened 
superior  lymphatic  duct  which  pierced  the  thyro- 
hyoid membrane,  and  eventually  became  lost  in  a 
general  glandular  mass  in  the  neck. 

Infection  of  the  pre-laryngeal  glands  is  fairly  rare. 
Most,  however,  has  seen  a  few  such  cases. 

Instead  of  occupying  the  border  of  the  crico-thyroid 
membrane,  the  infected  gland  may  be  found  placed 
over  the  middle  of  the  thyroid  cartilage  (Maas*)  or 
even  its  superior  depression  (Zeisslt).  There  seems 
to  be  no  record  of  infection  of  the  pre-tracheal  glands. 
Jurasz  and  Fraenkel  have  seen  the  glands  of  the 
recurrent  chain  involved  by  cancer.  Bergeat,;!; 
Maurer,§  and  Most  have  also  recorded  similar  cases ; 
but  in  all  the  verification  has  been  post-mortem,  as 
enlargement  of  these  glands,  owing  to  their  small 
size  and  depth,  cannot  be  recognised  clinically. 

It  was  also  at  a  post-mortem  examination  that 
Zeissl  found  a  case  of  involvement  of  the  retro- 
oesophageal  glands.  The  order  in  which  these 
different  groups  of  glands  become  infected  varies 
according  to  the  initial  seat  of  origin  of  the  laryngeal 

*  Maas,  Arch.f.  Klin.  Chir.^  Bd.  xix. 

t  Zeissl,  Wiener  Med.  Presse,  1881,  No.  44. 

%  Bergeat,  Monatschr.  f.  Ohrenheilk..,  1895,  P-  368- 

§   Maurer,  Berli)i  Klin.  Wochens.,  1882,  Nos.  26,  27. 


2  8     Malignant  Disease  of  the  Larynx 

growth.  When  the  disease  is  of  extrinsic  origin, 
glandular  infection  is  most  likely  to  occur  in  the 
upper  glands  of  the  sterno-mastoid  chain.  When 
intrinsic  and  above  the  glottis,  the  gland,  which  is 
first  found  to  be  enlarged  (according  to  Schwartz), 
is  placed  at  the  level  of  the  anterior  border  of  the 
sterno-mastoid  muscle,  about  the  height  of  the  space 
which  separates  the  hyoid  bone  from  the  thjToid 
cartilage ;  if  subglottic  in  origin,  the  lowermost 
glands  of  the  same  chain  are  generally  the  first  to  be 
attacked. 

Bearing  in  mind,  however,  the  many  ways  in 
which  the  lymphatic  vessels  draining  the  area  in 
question  may  terminate,  these  rules  obviously  have 
many  exceptions. 

Infection  of  the  pre-laryngo- tracheal  and  recurrent 
chains  implies  disease  attacking  the  subglottic  region. 
Inversely,  in  cases  of  growths  strictly  limited  to  the 
extrinsic  area  and  regions  of  the  true  and  false  vocal 
cords,  these  glands  remain  free. 

In  one  case  of  extrinsic  carcinoma  Cuneo  was 
able  to  prove  microscopically  the  absolute  immunity 
of  the  pre-laryngeal  glands,  although  the  glands 
appertaining  to  the  extrinsic  area  were  so  infected 
by  carcinoma  as  to  form  a  mass  as  large  as  one's  fist. 
So  long  as  one-half  of  the  larynx  only  is  affected,  the 
glands  only  on  that  side  are  infected. 

Most  and  Roubaud  were  unable  to  find  a  record 
of  any  case  in  which  a  unilateral  laryngeal  carcinoma 
had  caused  involvement  of  the  glands  on  both  sides. 
This  agrees  with  the  results  of  experimental  research 
and  of  the  pathological  anatomy  of  the  parts ;  for  it 


Carcinoma  of  the  Larynx  29 

has  already  been  pointed  out  that  an  injection  of  the 
lymphatics  of  one-half  of  the  larynx,  although  oc- 
casionally able  to  cross  the  median  line,  never 
penetrates  the  lymphatic  radicles  of  the  opposite 
side. 

Dissemination. 

There  is  no  matter  of  doubt  that  dissemination  in 
malignant  disease  of  the  larynx  is  extremely  rare. 
Out  of  eighteen  or  nineteen  post-mortems  for  carci- 
noma of  the  larynx  mentioned  in  Butlin's  mono- 
graph, dissemination  of  the  disease  was  recorded 
only  in  three  instances.  One  of  these  was  reported 
by  Sands,*  another  by  Desnos, t  the  third  by 
Schiffers.t 

In  the  first  case,  that  of  a  woman  aged  thirty,  the 
tumour  was  confined  to  the  left  vocal  cord.  The 
symptoms  commenced  in  September,  1862.  Laryn- 
gotomy  was  performed  in  January,  1865 — more  than 
two  years  and  a  quarter,  therefore,  after  the  com- 
mencement of  the  disease  There  was  no  affection 
of  the  glands  of  the  neck,  but  the  lumbar  glands  were 
enlarged,  and  the  left  suprarenal  capsule,  the  left 
kidney,  and  ureter  were  extensively  diseased. 

In  the  second  case,  that  of  a  man  whose  age  is  not 
recorded,  the  tumour  arose  in  the  left  aryepiglottic 
fold,  and  extended  down  to  the  ventricular  band. 
There  was  a  large  glandular  tumour  at  the  base  of 
the  neck  occupying  the  sheath  of  the  sterno-mastoid 

*  New  York  Medical  J ourjtal^  1865,  p.  no. 

f  Bull.  Soc.  Anat.,  4th  series,  vol.  iii.,  p.  398,  1878. 

X  Rev.  Mens,  de  Laryngologie^  1883,  p.  i. 


30    Malignant  Disease  of  the  Larynx 

muscle,  and  one  small  mass  of  carcinoma  was  em- 
bedded in  the  middle  of  the  right  lobe  of  the  liver. 
It  is  difficult  to  calculate  the  exact  duration  of  the 
disease  from  the  report,  but  it  had  probably  existed 
for  more  than  one  and  for  less  than  two  years. 

The  third  patient  was  a  man  fifty-three  years  old, 
who  was  first  attacked  with  hoarseness  during  March, 
1 88 1,  and  who  died  a  few^  days  before  Christmas. 
The  entire  left  half  of  the  larynx  was  diseased,  but 
the  tumour  w^as  thought  to  have  taken  its  origin  in 
the  false  vocal  cord.  The  glands  along  the  course 
of  the  jugular  vein  were  extensively  affected,  and  the 
lungs  contained  man}'  secondary  nodules,  varying  in 
size  from  a  pin's  head  to  a  nut.  No  operation  had 
been  performed. 

It  is  well  worthy  of  note  that  the  tumour  in  all 
these  cases  was  a  well-marked  specimen  of  squamous- 
celled  carcinoma  (epithelioma). 

Other  cases  have  been  recorded  —  for  instance, 
Isambert  has  recorded  a  case  of  epithelioma  of  the 
larynx,  with  carcinoma  of  the  prepuce.  Cadier,  a  case 
of  epithelioma  of  the  interarytenoid  space  in  a  patient 
who  had  been  operated  on  three  years  previously  for 
carcinoma  of  the  breast.  Thiersch  has  recorded  a 
case  similar  to  Schiffers.  Schmidt  has  seen  a  case 
of  cancer  of  the  larynx  after  carcinoma  of  the  breast. 
Poucet,  a  case  of  carcinoma  of  the  frontal  bone  in  a 
patient  with  carcinoma  of  the  right  aryepiglottic  fold. 
Mericamp,  a  case  of  carcinoma  of  the  left  aryepi- 
glottic fold  and  cricoid,  contemporaneous  with  carci- 
noma of  the  liver.  Latil,  a  case  of  cancer  of  the 
liver  together  with    cancer  of  the  false  vocal  cord. 


Carcinoma  of  the  Larynx  31 

Bronner  also  has  recorded  a  case  of  cancer  of  the 
epiglottis  with  metastasis  in  the  liver  and  lungs,  and 
Grayson  a  case  of  cancer  of  the  larynx  with  epithe- 
lioma of  the  lip.  Kocher,  a  man,  fifty-nine  years 
of  age,  who  died  two  years  after  partial  resection  of 
the  larynx.  There  was  no  local  recurrence,  but 
carcinoma  of  the  abdominal  cavity  was  found  post- 
mortem. 

Pinner-Schmidt  mentions  a  case  of  a  woman, 
forty-seven  years  of  age,  in  whom  partial  laryngec- 
tomy was  performed  for  cancer  of  the  larynx.  The 
patient  died  seven  years  later  of  cancer  of  the 
stomach.  It  is  a  question  whether  in  this  patient 
the  cancer  of  the  stomach  was  a  fresh  outbreak  of 
the  disease  or  a  secondary  growth  of  slow  progress. 

Schmiegelow,  again,  removed  half  the  larynx  in 
a  female  aged  forty -six,  who  was  suffering  from 
carcinoma.  She  died  ten  months  later  of  carcinoma 
of  the  stomach.    There  was  no  local  recurrence. 

Morian  performed  a  similar  operation  on  a  male 
aged  forty  -  seven,  who  died  seven  weeks  later. 
Secondary  growths  were  found  in  the  lungs.  There 
w^as  no  local  recurrence. 

Wolff  performed  total  laryngectomy  in  a  male 
aged  forty-one.  The  patient  died  two  and  a  half 
years  later  with  secondary  growths  in  the  bones  and 
lungs. 

Both  Schrotter  and  Fauvel,  men  of  wide  experience 
in  laryngology,  have  not  seen  a  single  case  of  metas- 
tasis, and  Morell  Mackenzie  only  once  came  across 
such  a  condition  in  his  practice. 

It  is  surely  a  remarkable  circumstance  that  dis- 


32    Malignant  Disease  of  the  Larynx 

semination  should  occur  so  rarely  of  a  disease  which 
in  many  instances  produces  death  slowly,  and  has, 
therefore,  ample  time  to  become  generalized.  And  it 
is  still  more  remarkable  that  in  the  few  cases  in 
which  dissemination  is  actuall}^  known  to  have 
occurred  the  abdominal  viscera  rather  than  the  lungs 
were  affected  (abdominal  viscera,  8  cases ;  lungs, 
4  cases;  both  regions,  i  case). 

It  has  elsewhere  been  pointed  out*  that  carcinoma 
of  the  oesophagus  apparently  only  affects  the  lungs 
under  what  may  be  termed  very  favourable  condi- 
tions— when,  for  example,  fragments  of  a  tumour 
which  has  penetrated  into  the  air-passages  are  carried 
into  the  terminal  or  almost  terminal  bronchial  tubes. 
Here,  however,  is  a  disease  situated  generally  im- 
mediately over  or  within  the  entrance  to  the  air- 
passages,  therefore,  as  one  might  suppose,  constantly 
furnishing  fragments  which  are  carried  into  the  lungs 
with  the  inspired  air,  yet  scarcely  under  any  condi- 
tions obtaining  a  hold  upon  them.  The  rule  is  the 
same  not  only  for  the  squamous-celled  carcinomas, 
which  we  are,  most  of  us,  inclined  to  regard  as  little 
liable  to  dissemination,  but  also  for  the  spheroidal- 
celled  carcinomas,  which  in  the  larynx,  as  in  other 
parts,  are  sometimes  very  soft  and  cellular,  and 
therefore  of  the  kind  most  given  to  dissemination. 

There  are,  of  course,  some  conditions  which  may 
possibly  be  regarded  as  modifying  the  conclusions 
which  have  been  drawn  from  post-mortem  examina- 
tions. In  the  first  place,  death  has  resulted  directly 
from  operation  in  many  cases,  and  although  the 
*  Butlin,  '  Sarcoma  and  Carcinoma.' 


Carcinoma  of  the  Larynx  ;^;^ 

disease  in  many  of  these  lasted  for  a  long  time,  it 
may  fairly  be  said  that  its  natural  course  was  cut 
short. 

In  the  second  place,  although  the  disease  was 
situated  over  the  entrance  to  the  air-passages,  and 
fragments  were  liable  to  be  sucked  in  during  inspira- 
tion, tracheotomy  was  performed  in  several  instances, 
and  this  danger,  therefore,  to  a  certain  extent  was 
averted.  In  many  cases,  however,  in  which  an 
autopsy  was  made  no  operation  had  been  performed ; 
and  even  in  those  cases  in  which  the  trachea  had 
been  opened  there  was  nothing  to  prevent  dissemina- 
tion through  the  circulation,  by  far  the  most  frequent 
medium  for  the  dissemination  of  malignant  disease 
generally.  It  is  certainly  most  difficult  to  under- 
stand why  a  malignant  disease  situated  in  so 
important  an  organ  should  be  so  little  given  to  dis- 
semination. It  is  the  more  difficult  to  understand 
because  experience  shows  that  carcinoma  of  the 
larynx  is  in  other  respects  a  very  malignant  disease, 
and  has  been  until  quite  recent  times  very  little 
amenable  to  radical  treatment. 

Histological  Structure. 

All  authorities  agree  that  epithelioma  is  the  variety 
of  cancer  that  attacks  the  larynx  the  most  frequently. 
Encephaloid  (carcinoma  medullare),  scirrhus,  and 
cylindrical  -  celled  carcinomas  have  all  been  met 
with  in  the  larynx,  but  are,  especially  the  last  two 
varieties,  exceedingly  rare. 

Schwartz,  out  of  103  cases   of  laryngeal  cancer, 

3 


34    Malignant  Disease  of  the  Larynx 

found  54  to  be  epithelioma  ;  Schrotter,  out  of  20 
cases,  17  ;  Ziemssen,  out  of  68  cases,  57.  Sendziak 
notes  248  cases  in  his  statistics,  and  Semon,  out  of 
103  cases,  40  epithehomas. 

Cyhndrical  or  columnar-celled  carcinoma  appears 
to  be  exceedingly  rare.  Only  a  few  cases  are  to  be 
found  in  the  literature  of  the  subject.  It  is  some- 
what surprising  that  columnar-celled  carcinoma  is 
not  more  common  in  the  larynx,  for  the  origin  of  the 
disease  is  by  no  means  limited  to  those  tracts  of  the 
mucous  membrane  which  are  covered  with  squamous 
epithelium. 

Apparently  the  influence  which  suffices  during 
health  to  maintain  the  normal  relation  between  the 
two  varieties  of  epithelium,  confining  each  variety  to 
its  particular  areas,  and  suffering  neither  to  intrude 
upon  the  other,  disappears  under  pressure  of  disease, 
and  the  squamous  epithelium,  being,  as  it  were,  the 
stronger  and  more  enduring  variety,  impresses  its 
form  upon  the  elements  of  the  cancer,  which  thus 
becomes  a  squamous-celled  carcinoma. 


SYMPTOMS. 

The  symptoms  of  carcinoma  of  the  larynx,  especi- 
ally in  the  early  stages,  depend  to  a  certain  extent,  as 
might  be  expected,  on  the  situation  of  the  growth. 
There  is  no  one  symptom  that  is  absolutely  diagnostic 
of  the  disease. 

The  intrinsic  growths  usually  commence  with 
hoarseness  and  occasionally  slight  cough,  symptoms 


Carcinoma  of  the  Larvnx  35 

which  indicate  a  laryngeal  catarrh  rather  than  a 
more  serious  affection. 

Considerable  importance,  however,  attaches  to  this 
hoarseness.  It  is  frequently  the  only  symptom  of 
early  malignant  disease  involving  the  true  vocal  cords 
or  anterior  commissure,  and  may  last  as  long  as  a 
year  without  any  other  evidence  of  malignant  disease 
presenting  itself. 

A  most  careful  laryngoscopic  examination  should 
always  be  made  in  any  middle-aged  patient  who 
complains  of  obstinate  hoarseness  of  any  appreciable 
duration,  even  if  there  be  no  other  symptom  of  any 
kind. 

As  the  disease  advances  and  ulceration  supervenes, 
the  hoarseness  increases,  and  the  voice  may  eventually 
be  entirely  lost.  The  extrinsic  growths,  especially 
those  of  the  epiglottis  and  arytenoids,  more  often 
produce  dysphagia  than  hoarseness,  and  it  is  not 
until  the  disease  is  far  advanced  and  the  intrinsic 
muscles  or  cartilages  are  involved  that  vocal  and 
respiratory  troubles  are  observed. 

Involvement  of  the  neighbouring  glands  and 
pressure  on  the  recurrent  laryngeal  nerves,  or  dis- 
placement of  the  arytenoid  cartilages,  will,  when 
present,  affect  the  voice  in  extrinsic  carcinoma. 
When  the  cricoid  plate  is  primarily  affected,  early 
and  extensive  involvement  of  the  neighbouring  glands 
is  the  rule. 

Difficulty  and  pain  in  swallowing,  the  secretion 
of  frothy  and  blood-stained  mucus,  are  also  early 
symptoms  of  carcinoma  of  the  cricoid  plate.  Involve- 
ment of  the  glands  under  the  angle  of  the  jaw,  and 

3—2 


J 


6    Malignant  Disease  of  the  Larynx 


subsequently  along  the  whole  length  of  the  sterno- 
mastoid,  soon  follows,  and  as  the  growth  increases  in 
size,  not  only  does  the  dysphagia  increase,  but 
dyspnoea  becomes  marked  and  urgent.  The  dyspncea 
is  due  to  involvement  of  the  muscular  substance  of 
the  posterior  crico-arytenoid  muscles  and  their  sub- 
sequent myopathic  paralysis,  with  gradual  narrowing 
of  the  glottis  (Semon). 

Again,  pain  is  a  symptom  which  belongs  especially 
to  extrinsic  tumours,  although  it  is  by  no  means 
unknown  in  cases  of  intrinsic  tumour.  The  pain  is 
sometimes  peculiarly  severe,  and  is  not  limited  to  the 
larjmx  or  even  to  the  parts  around,  but  radiates  over 
the  whole  of  the  neck  on  the  affected  side  and  is 
frequently  complained  of  in  the  ear,  resembling  in 
these  respects  the  referred  pain  in  cases  of  toothache 
and  of  hip  disease. 

In  some  of  the  cases  of  intrinsic  carcinoma  no  pain 
is  experienced  during  the  whole  course  of  the  disease ; 
in  other  cases,  although  the  pain  is  not  spontaneous, 
it  is  produced  by  swallowing  or  speaking. 

The  radiating  pains  to  the  ear  are,  however,  very 
characteristic  of  malignant  disease,  and  are  not  so 
frequently  noted  in  other  affections  of  the  larynx. 
They  are  probably  due  to  irritation  of  the  fibres  of 
the  superior  lar}''ngeal  nerve  by  the  growth ;  this 
irritation  is  referred  to  the  auricular  branch  of  the 
pneumogastric  nerve,  and  thus  pain  is  felt  in  the  ear. 
In  a  few  cases  local  tenderness  on  pressure  has  been 
present. 

Expectoration  is  in  some  cases  very  abundant, 
but  it  is  rarely  so  unless  the  growth  is  deeply  ulcerated 


Carcinoma  of  the  Larynx  '^^'j 

or  extensive.  The  sputa  are  at  first  usually  frothy, 
but  later  become  purulent,  and  may  be  stained  or 
streaked  with  blood ;  there  may  be  considerable 
fcetor  of  a  sickly,  musty  odour  and  cough,  especially 
in  the  later  stages,  from  breaking  down  of  the 
malignant  masses.  Sometimes  a  fragment  of  the 
growth  or  even  of  the  cartilages  of  the  larynx  is 
coughed  up. 

Haemorrhage  is  an  unusual  symptom,  and  scarcely 
ever  occurs  unless  the  disease  has  extended  to  the 
tongue  or  neighbouring  vessels,  but  few  fatal  cases 
are  recorded  as  actually  resulting  from  haemorrhage. 
In  one  the  base  of  the  tongue  was  extensively 
affected,  and  in  four  or  five  others  repeated  bleedings 
hastened,  although  they  did  not  actually  produce, 
the  fatal  result  (Tiirck,  Dreyfuss,  Desnos,  Maydl). 

Dyspncea. — Occasional  attacks  of  dyspnoea  show 
that  the  gravity  of  the  disease  has  been  underrated. 
It  usually  at  first  shows  itself  on  exertion,  and  is 
generally  due  to  direct  obstruction  by  the  tumour, 
although  infiltration  and  consequent  weakness  of  the 
intrinsic  laryngeal  muscles  plays  an  important  part. 
Later  on  in  the  progress  of  the  disease  there  may  be 
very  severe  paroxysms  of  dyspnoea  due  to  glandular 
pressure  on,  or  involvement  of,  the  laryngeal  nerve 
or  trachea,  in  other  cases  to  oedema  or  stenosis  of 
the  glottic  aperture. 

Dysphagia  has  already  been  referred  to  as  an 
early  symptom  when  the  site  of  the  disease  is  the 
epiglottis  or  arytenoid  region.  It  is  uncommon  in 
cases  of  carcinoma  of  the  true  or  false  vocal  cords. 
Scheier  in  102  cases  noted  its  presence  in  only  15 


38    Malignant  Disease  of  T£iE  Larynx 

cases,  and  in  each  of  these  there  was  ulceration 
present. 

In  a  few  rare  cases  the  symptoms  are  from  the 
very  first  those  of  perichondritis  (pain,  fever,  dys- 
phagia, and  alteration  of  the  voice),  and  in  such  cases 
errors  of  diagnosis  are  likely,  the  disease  tending  to 
be  mistaken  for  tubercle  or  syphilis  of  the  larynx. 

Cachexia  is  far  less  common  than  in  carcinoma 
attacking  other  parts  of  the  body ;  it  is  especially 
infrequent  in  intrinsic  carcinoma.  When  the  growth 
is  of  extrinsic  origin  and  the  neighbouring  glands 
have  become  involved  cachexia  may  supervene,  but 
even  in  these  cases  it  does  not  become  marked  until 
the  disease  has  reached  a  very  advanced  stage. 

This  comparative  immunity  to  cachexia  is  in 
accordance  with  the  rarity  of  dissemination  of  the 
disease,  and  is  probably  attributable  to  the  lymphatic 
isolation  of  the  larynx  already  referred  to  under 
Pathology. 

SIGNS. 

The  appearance  of  the  disease  as  seen  by  the 
laryngoscope  varies  somewhat  according  to  its  situa- 
tion. 

Carcinoma  of  the  epiglottis  sometimes  appears 
as  a  destructive  ulceration,  but  more  frequently  it 
presents  itself  as  a  distinct  and  nodular  tumour  of  a 
grayish  or  pinkish  white  colour,  which  may  be 
limited  to  the  epiglottis,  or  may  extend  to  the  base 
of  the  tongue,  the  lateral  walls  of  the  pharynx, 
oesophagus,    or    to    the    aryepiglottic    folds.      The 


Carcinoma  of  the  Larynx  39 

affected  part  is  from  an  early  stage  seen  to  be  fixed, 
and  if  the  finger  be  inserted  into  the  mouth  the  epi- 
glottis will  be  felt  to  be  hard  to  the  touch.  The 
primary  tumours  of  the  arytenoids  and  the  ary- 
epiglottic  folds  are  generally  masses  of  considerable 
size,  and  present  the  same  outward  characters, 
whether  they  are  squamous-celled  or  sphenoidal-celled 
carcinomas. 

If  ulceration  is  present,  the  ulcer  is  characterized 
by  its  irregular  crateriform  shape,  its  heaped-up 
everted  edges,  its  foul  sanious  discharge,  and  by  the 
very  early  immobility  of  the  part  affected.  Fungating 
granulations  of  a  reddish  colour  sprout  up,  and  may 
be  seen  one  day  and  be  found  to  have  almost  dis- 
appeared the  next.  When  the  perichondrium  be- 
comes involved  considerable  oedema  may  be  present 
surrounding,  and  possibly  obscuring,  the  original 
growth. 

If  the  disease  presents  as  a  distinct  mass  or 
masses,  it  may  at  first  resemble  simple  papillomata. 
The  tumour,  however,  in  malignant  disease  has  a 
broader  base,  is  of  firmer  consistency,  and  tends 
early  to  deep  infiltration  of  the  neighbouring  parts. 

Malignant  disease  of  the  ventricular  bands  may 
appear  as  a  unilateral  tumefaction,  as  a  general 
infiltration  pinkish  or  reddish  in  colour,  with  a 
coarsely  mammillated  uneven  surface,  or  may  present 
itself  as  a  definite  tumour,  sessile,  solitary,  dusky-red 
in  colour,  sometimes  smooth,  but  more  often  ir- 
regular in  shape,  and  frequently  closely  resembling 
a  wart  in  appearance. 

On  the  vocal  cords  carcinoma  in  the  early  stages 


40    Malignant  Disease  of  the  Larynx 

may  present  itself  as  (a)  a  unilateral  congestion  or 
swelling,  the  unilateral  character  of  the  swelling 
being  always  suggestive  of  commencing  malignancy; 
(b)  as  an  infiltrating  growth  of  a  reddish  and  uneven 
surface,  and  no  tendency  to  limitation  ;  (c)  as  a 
single  reddish  or  pinkish  sessile  growth,  sometimes 
ulcerated,  and  very  like  a  papilloma,  more  rarely  a 
fibroma,  in  character. 

If  the  growth  be  pedunculated,  the  similarity  to  a 
papilloma  or  fibroma  becomes  more  marked.  In  a 
case  observed  by  Semon  the  papillomatous  appear- 
ance of  a  small  epithelioma  was  masked  by  a  large 
blood-clot  which  had  formed  round  the  papillomatous 
excrescences,  the  new  growth  being  taken  by  several 
observers  for  an  angioma. 

A  zone  of  circumscribed  hypersemia  surrounding  a 
malignant  new  growth  is  not  by  any  means  infre- 
quent, and  is  particularly  noticeable  when  the  growth 
occupies  the  mid  region  of  the  vocal  cord,  the 
anterior  and  posterior  parts  of  the  cord  standing  out 
a  brilliant  white,  in  marked  contrast  to  the  hyper- 
yemic  area. 

Here,  again,  in  growths  or  infiltrations  attacking 
the  true  vocal  cords,  and  of  a  malignant  nature, 
impairment  of  mobility  of  the  vocal  cord  becomes  a 
sign  of  the  greatest  importance,  and  is  again  referred 
to  more  fully  under  Differential  Diagnosis.  Malignant 
disease  of  the  larynx  is  usually  insidious  in  its  onset, 
extending  somewhat  slowly,  yet  surely,  at  first. 
Later  on  it  advances  rapidly,  growing  in  size  and 
invading  the  neighbouring  parts  of  the  larynx.  Car- 
cinoma commencing  on  one  of  the  true  or  false  vocal 


Carcinoma  of  the  Larynx  41 

cords  is  somewhat  liable  to  spread  to  the  fellow  cord 
on  the  opposite  side. 

Whether  the  disease  be  squamous  or  spheroidal- 
celled,  it  generally  presents  the  same  outward 
characters,  so  that  it  is  rarely  possible  to  tell  from 
the  macroscopic  characters  to  which  variety  it 
belongs. 

Ulceration  is  very  common,  almost  as  much  so  of 
the  spheroidal-celled  as  of  the  squamous-celled  carci- 
nomas. The  time  within  which  ulceration  becomes 
apparent  is  liable  to  considerable  variation  in  indi- 
vidual cases.  Sometimes  it  is  seen  within  three  or 
four  months  from  the  onset  of  the  disease,  in  other 
cases  ulceration  may  be  delayed  for  a  much  longer 
period,  even  for  so  long  as  a  year  and  a  half  from  the 
commencement  of  the  disease.  In  many  cases  the 
destruction  and  resulting  deformity  and  displacement 
is  very  great,  and  constitutes  a  most  striking  character 
of  the  disease. 

In  the  later  stages,  whether  the  disease  be  of 
intrinsic  or  extrinsic  origin,  the  entire  larynx  is  liable 
to  become  involved.  The  tumours  which  arise 
within  the  larynx  occupy  the  whole  of  the  cavity, 
and  when  involving  the  cartilaginous  framework 
marked  broadening  and  tenderness  of  the  larynx  may 
be  seen  and  felt.  Sometimes  the  growth  perforates 
the  cartilages  or  passes  between  them,  invading 
rapidly  the  surrounding  muscles,  and  finally  present- 
ing as  a  fungating  mass  through  the  skin. 

The  tumours  which  arise  in  the  outer  portions  of 
the  larynx  pass  down  the  sides  and  into  the  cavity, 
and  destroy  large  pieces  of  the  cartilage  and  mucous 


42    Malignant  Disease  of  the  Larynx 

membrane.  When  once  the  disease  has  reached  the 
stage  in  which  the  whole  larynx  is  more  or  less 
involved,  and  transformed  into  a  mass  of  broken- 
down  ulcerating  tissue,  with  prominent  exuberant 
masses  of  granulations,  and  in  most  cases  glandular 
involvement,  there  can  usually  be  no  difficulty  in 
diagnosis.  Unfortunately,  in  this  stage  but  little,  if 
anything,  can  be  done  for  the  patient. 

It  is  of  importance  to  remember  that  it  is  some- 
times impossible  to  limit  from  the  laryngoscopic 
picture  the  extent  of  the  disease  present.  Even  when 
the  growth  forms  a  mass  as  large  as  a  nut  or  larger, 
it  may  be  so  situated  that  only  its  upper  surface  is 
visible  on  laryngoscopic  examination. 

If  left  to  pursue  its  course,  malignant  disease  of 
the  larynx  usually  ends  fatally  within  three  years  of 
its  appearance.  With  progressive  emaciation  the 
patient  becomes  feebler  and  feebler  and  dies.  In 
some  cases  an  intercurrent  affection  such  as  bron- 
chitis or  *  foreign  body '  pneumonia,  due  to  the 
inhalation  of  secretion  or  particles  of  the  growth  or 
food,  ends  the  scene.  In  others  a  fatal  termination 
results  from  sudden  or  repeated  hsemorrhages,  dysp- 
noea, or  severe  dysphagia. 

DIAGNOSIS. 

The  diagnosis  of  an  advanced  carcinoma  is  in 
most  instances  very  easy.  The  extensive  ulceration, 
the  implication  of  several  structures,  the  destruction 
wrought  by  the  disease,  the  steady  progress  of  the 
symptoms,  the  radiating  pain  and  pain  in  the  ear. 


Carcinoma  of  the  Larynx  43 

and  (in  cases  of  extrinsic  cancer)  the  enlargement  of 
the  lymphatic  glands,  exclude  all  doubt  of  the  malig- 
nant nature  of  the  malady.  But  in  the  earlier 
stages  the  diagnosis  is  often  beset  with  difficulties, 
and  may  be  impossible. 

The  principal  points  to  lay  especial  stress  on  in 
early  malignant  disease  of  the  larynx  are  the  age  and 
sex  of  the  patient,  the  symptoms,  especially  that  of 
hoarseness  without  obvious  cause,  and  the  presence 
or  absence  of  any  constitutional  diathesis,  the  laryn- 
goscopic  appearances,  and  whenever  possible  the 
removal  and  examination  microscopically  of  a  frag- 
ment or  fragments  of  the  growth  by  a  skilled 
pathologist. 

If  too  small  or  too  superficially  extirpated  frag- 
ments be  examined,  mistakes  may  be  made.  When  a 
fragment  has  been  removed  for  microscopic  examina- 
tion, several  sections  should  be  cut  and  carefully 
examined.  If  no  evidence  of  malignancy  be  found, 
it  is  advisable,  if  the  clinical  symptoms  justify  it,  to 
remove  a  further  and  deeper  part  of  the  growth  and 
subject  it  to  a  similar  careful  examination. 

Cases  are  on  record  of  tumours  partaking  of  a 
mixed  character  —  i.e.,  papilloma  and  carcinoma 
(Semon)  being  present  in  the  larynx. 

It  is  important  to  bear  in  mind  that  a  negative 
verdict  by  the  pathologist  is  not  sufficient  to  set 
aside  clinical  appearances  when  they  are  markedly 
suggestive  of  a  malignant  type.  It  devolves  on  the 
surgeon  in  such  cases  to  have  the  courage  of  his 
own  opinion,  and  to  be  prepared  to  form  a  definite 
diagnosis  from  clinical  signs  alone. 


44     Malignant  Disease  of  the  Larynx 

A  differential  diagnosis  has  to  be  made  from 
inflammatory  diseases,  benign  laryngeal  tumours, 
pachydermia  laryngis,  syphilis,  tubercle,  lupus,  laryn- 
geal paralyses  and  perichronditis.  From  chronic 
laryngitis  malignant  disease,  if  associated  with  marked 
hyperaemia,  can  usually  be  diagnosed  by  its  unilateral 
character,  the  contrast  if  a  vocal  cord  be  affected 
with  the  normally  white  one  being  very  marked. 

At  the  same  time  it  is  well  to  remember  that  cases 
have  occurred,  although  rarely,  in  which  apparently 
simple  bilateral  congestion  of  the  vocal  cords  has 
preceded  malignant  disease  ;  the  possibility,  therefore, 
of  malignancy  should  be  borne  in  mind  if  an  appar- 
ently simple  chronic  laryngitis,  even  though  bilateral, 
does  not  yield  to  its  usual  remedies  (Semon). 

As  time  goes  on  a  most  important  sign  becomes 
noticeable — namely,  sluggishness  of  movement  of 
the  affected  vocal  cord,  '  impaired  mobihty.'  This 
impaired  mobility  is  often  present  at  a  very  early 
stage  of  the  disease,  but  naturally  varies  according 
to  the  situation  of  the  disease.  For  instance,  in 
cases  where  the  origin  of  the  growth  is  the  ventricle 
of  Morgagni,  the  cord  on  the  affected  side  may  be 
entirely  covered  by  the  mass,  but  yet  be  quite  free  in 
its  movements. 

This  sign,  to  which  Semon  was  the  first  to  draw 
attention,  is  of  great  diagnostic  importance,  and  has 
been  but  little  understood  and  valued  on  the  Con- 
tinent. In  England  its  value  has  been  fully  appre- 
ciated, and  has  certainly  helped  enormously  in  correct 
diagnosis  of  early  malignant  disease  of  the  vocal 
cords.    Of  this  sign  Semon  ('Encyclopaedia  Medica') 


Carcinoma  of  the  Larynx  45 

says  :  '  The  value  of  this  sign,  to  which  I  was  the  first 
to  draw  attention,  has  been  repeatedly  decried,  and 
my  utterances  on  this  subject  have  been  curiously 
misunderstood  by  some  Continental  authors.  I  wish, 
therefore,  to  declare  as  plainly  as  possible  that  I 
neither  believe  such  impairment  of  mobility  to  be 
present  in  every  case  of  early  malignant  disease  of  the 
vocal  cords,  nor  that  its  absence  in  any  way  militates 
against  the  disease  being  malignant.  All  I  contend 
is  that  if  in  the  case  of  a  doubtful  growth  springing 
from  a  vocal  cord — and  not  only  when  the  growth  is 
situated  near  the  crico-arytenoid  articulation,  but 
even  in  the  anterior  part  of  the  vocal  cord — an 
impairment  of  mobility — i.e.,  some  sluggishness  of 
the  movements  of  the  affected  cord — is  observed,  this 
is  a  most  valuable  sign,  pointing  to  the  malignant 
nature  of  the  affection.' 

From  benign  laryngeal  tumours  (papilloma,  fibroma, 
cysts),  the  presence  or  absence  of  infiltration,  the  age 
of  the  patient,  and  the  plurality  of  the  growths  are 
among  the  most  important  points  to  determine.  It 
is  also  of  great  importance  to  note  the  site  of  the 
growth.  A  malignant  neoplasm  may  grow  from  any 
part  of  the  vocal  cord,  but  most  frequently  arises 
from  the  middle  or  posterior  third  of  the  vocal  cord ; 
when  a  growth  is  seen  to  originate  in  these  situations 
in  a  patient  over  fifty  years  of  age  it  is  always  to  be 
looked  upon  as  suspicious,  and  is  not  the  usual  seat 
of  origin  of  benign  papilloma. 

It  is  especially  the  differential  diagnosis  between 
papillomata  and  malignant  disease  that  is  often  so 
difficult.     Besides  the  points  already  referred  to,  the 


46    Malignant  Disease  of  the  Larynx 

mobility  and  more  circumscribed  appearance  of  the 
papilloma,  together  with  its  consistency,  the  younger 
age  of  the  patient,  the  length  of  time  the  disease  has 
existed,  and  the  free  mobility  of  the  vocal  cord  or 
cords  are  the  main  signs  to  be  guided  by. 

Usually,  too,  the  papillae  in  the  benign  growth  are 
much  longer  and  coarser  than  in  a  warty  carcinoma, 
their  tips  are  rounded  instead  of  pointed,  and  if  the 
colour  of  the  tumour  be  snowy  white  instead  of  a 
pinkish  colour,  as  is  usual  in  laryngeal  papilloma, 
there  is  still  further  corroborative  evidence  of  the 
malignant  nature  of  the  growth. 

In  fibroma  the  tumour  is  generally  of  globular 
shape,  does  not  tend  to  ulcerate,  and  when  growing 
from  a  vocal  cord,  however  large  it  may  tend  to 
become,  never  causes  any  impairment  of  mobility  of 
the  cord  ;  whereas  in  malignant  disease,  even  if  the 
growth  be  semiglobular  in  form  to  begin  with,  it 
tends  to  become  mammillated,  to  ulcerate,  and  to 
cause  impairment  of  mobility  of  the  affected  vocal 
cord.  If  after  removal  of  an  apparently  innocent 
growth  rapid  recurrence  takes  place  or  a  dirty, 
sloughy  ulcer  is  left,  malignant  disease  is  to  be  sus- 
pected, especially  if  the  patient  be  beyond  middle 
age. 

From  Pachydermia  laryngis  {Pachydermia  verucosa 
of  Virchow)  the  diagnosis  is  made  by  the  typical 
appearance  presented  by  the  latter  disease — namely, 
in  the  early  stages  symmetrically-placed  wart-like 
growths  occupying  the  posterior  third  of  the  vocal 
cords  or  interarytenoid  space,  and  in  the  later  stages 
the  crateriform  depression  at  the  top  of  one  tume- 


Carcinoma  of  the  Larynx  47 

faction  with  a  corresponding  elevation  on  the  other. 
Moreover,  the  cords  remain  freely  movable,  there  is 
very  much  less  hoarseness  than  in  malignant  disease, 
and  there  is  usually  a  well-marked  history  of  chronic 
alcoholism.  From  syphilis  of  the  larynx,  especially 
when  the  latter  presents  itself  in  an  ulcerative  form, 
the  diagnosis  is  often  replete  with  difticulties,  and 
particularly  so,  as  cases  of  the  two  diseases  being 
present  together  have  been  recorded  (Hunter,  Mac- 
kenzie). 

There  is  generally  a  marked  absence  of  pain  in 
syphilitic  ulcerations  of  the  larynx,  and  the  ulcers 
that  form  as  a  result  of  the  breaking  down  of 
gummata  are  usually  sharply  cut  out  and  depressed, 
and  extend  rapidly,  at  first,  from  the  centre  to  the 
periphery.  Their  base  generally  shows  a  more  or 
less  typical  wet  chamois-leather-like  slough.  If  the 
syphilitic  ulcer  be  solitary,  it  rarely  becomes  as  large 
in  size  as  a  carcinomatous  one.  Later  on  cicatriza- 
tion with,  possibly,  extensive  deformity  and  stenosis 
results. 

In  other  cases  a  diffuse  infiltration  attacks  the 
epiglottis,  vocal  cords,  or  interarytenoid  fold.  The 
extent  of  the  infiltration  and  the  absence  of  any 
distinct  growth  are  usually  sufficient  to  prevent  a 
diagnosis  of  malignant  disease  being  made. 

Other  manifestations  of  syphilis  may  be  present. 
At  any  rate,  in  cases  of  doubt,  even  when  syphilis  is 
not  suspected,  it  is  a  good  rule  to  administer  iodide 
of  potassium  10  grains  internally,  and  to  gradually 
increase  the  dose  to  30  grains  three  times  a  day. 
Careful  note  should  be  made  of  any  changes  in  the 


48    Malignant  Disease  of  the  Larynx 

size  or  extent  of  the  ulcers  or  infiltration,  for  it 
should  be  remembered  that  an  apparent  improve- 
ment may  follow  on  the  administration  of  iodide  of 
potassium  in  malignant  disease,  due  not  to  any 
effect  on  the  growth  itself,  but  to  resorption  of  the 
surrounding  inflammatory  oedema.  This  improve- 
ment is,  of  course,  only  temporary. 

From  tubercle,  as  a  rule,  the  diagnosis  is  easy,  yet 
there  are  many  cases  in  which  it  is  extremely  difficult 
to  give  a  definite  opinion.  Patients  suffering  from 
tuberculosis  of  the  larynx  are  usually  of  a  younger 
age  than  those  attacked  by  malignant  disease.  The 
affection  is  generally  bilateral — in  malignant  disease, 
at  any  rate — in  its  earlier  stages  unilateral.  There  is 
more  or  less  actual  tumour  formation  in  tuberculosis, 
and  the  ulcers  that  form  are  generally  multiple, 
superficial,  and  of  a  '  mouse-nibbled '  appearance  at 
the  edges.  CEdema  and  pallor  of  the  surrounding 
parts,  especially  of  the  epiglottis  and  arytenoids,  are 
usually  well  marked,  and  the  condition  of  the  lungs 
and  sputa  on  examination  will  generally  give  corro- 
borative evidence.  Cases  have,  although  rarely,  been 
published  in  which  carcinoma  of  the  throat  has 
co-existed  with  general  phthisis  (Wolfenden). 

From  lupus,  the  youth  of  the  patient,  the  very  slow 
progress  of  the  disease,  the  resulting  cicatrization  and 
deformity,  the  absence  of  pain,  and  the  presence  of 
the  same  disease  in  other  parts,  as  the  pharynx  or 
skin,  render  the  differential  diagnosis  sufficiently 
easy.  From  various  forms  of  paralysis  difficulties  in 
differential  diagnosis  are  not  likely  to  occur. 

Semon,  however,  has  seen  two  cases  in  which  the 


Carcinoma  of  the  Larynx  49 

appearances  were  absolutely  those  of  bilateral  ab- 
ductor paralysis,  the  vocal  cords  lying  close  to  one 
another  in  the  mid-line  of  the  larynx.  The  subse- 
quent history  proved  that  this  appearance  was  due  to 
subglottic  malignant  disease,  in  one  case  to  an  epi- 
thelioma, in  another  to  sarcoma. 


PROGNOSIS. 

There  can  be  no  manner  of  doubt  that  the  prog- 
nosis of  any  given  case  of  carcinoma  of  the  larynx 
varies  very  greatly  according  to  (a)  the  original  site 
of  the  growth ;  (6)  the  period  at  which  the  disease 
comes  under  observation ;  (c)  the  general  health  of 
the  patient. 

There  is  nothing  more  remarkable  in  the  recent 
operative  work  on  cancer  generally  than  the  results 
obtained  by  radical  operation  in  certain  cases  01 
cancer  of  the  larynx.  If  the  disease  be  of  intrinsic 
origin,  limited  in  extent — that  is  to  say,  seen  and 
diagnosed  in  an  early  stage — the  patient  not  too  old, 
and  in  fairly  good  general  health,  and  willing  to 
undergo  immediate  operation,  the  very  best  results 
may  be  anticipated  with  safety.  At  any  rate,  in 
England  such  cases  operated  on  almost  entirely,  be 
it  said,  by  thyrotomy,  have  resulted  within  recent 
years  in  lasting  cures  exceeding  80  per  cent.  Such 
results  speak  for  themselves. 

By  contrast,  however,  the  prognosis  becomes 
increasingly  grave  in  cases  where  the  disease, 
although  of  intrinsic  origin,  has  become  very  exten- 

4 


50    Malignant  Disease  of  the  Larynx 

sive  ;  when  the  lymphatic  glands  have  become  in- 
volved, the  patient  is  old  and  his  general  health  bad. 
The  prognosis  is  always  grave  in  cases  of  extrinsic 
origin  by  virtue  of  the  early  lymphatic  involvement, 
and  especially  so  in  carcinoma  affecting  the  cricoid 
plate.  Nevertheless,  it  must  be  remembered  that 
recent  improved  methods  of  operation  have  even  in 
these  bad  cases  given  some  exceptionally  good 
results,  notably  at  the  hands  of  Gluck,  of  Berlin, 
although  the  patients  are  of  necessity  subjected  to 
loss  of  the  whole  larynx,  and  a  consequent  very 
pitiable  after-condition. 


TREATMENT. 

The  treatment  of  carcinoma  of  the  larynx  may 
best  be  discussed  under  two  headings  : 

1.  Radical  treatment  by  operation. 

2.  Palliative  treatment. 


Radical  Treatment. 

Methods  of  Operation — (i)  Endolaryngeal  Re- 
moval.— Although  removal  of  the  disease,  whether 
sarcoma  or  carcinoma,  per  vias  naturales  has  in  a 
few  instances  been  attended  with  brilliant  results,  this 
method  should  only  exceptionally  be  resorted  to. 
It  is  undoubtedly  founded  on  wrong  surgical  prin- 
ciples. As  in  malignant  disease  elsewhere,  malignant 
disease  is  from  the  beginning  of  an  infiltrating  nature, 
and  for  its  extirpation  it  is  essential  that  a  sufficiently 


Carcinoma  of  the  Larynx  51 

wide  area  of  the  surrounding  healthy  tissues  be 
removed  with  the  growth.  This  can  but  rarely  and 
with  no  degree  whatever  of  certainty  be  accomplished 
by  endolaryngeal  operations.  Moreover,  it  is  a  well- 
known  fact  that  the  infiltration  in  malignant  disease 
is  nearly  always  of  much  greater  extent  than  would 
have  been  thought  from  the  laryngoscopic  examina- 
tion. 

The  class  of  cases  in  which  it  may  be  employed 
are  those  in  which  the  disease  is  found  to  be  very 
limited  and  quite  on  the  edge  of  the  vocal  cord,  and 
in  which  extreme  old  age  or  very  serious  impairment 
of  the  health  preclude  an  external  operation,  or  in 
which  the  patient  refuses  any  external  operation. 

The  uncertainty  of  the  method,  the  probability 
that  the  disease  will  not  be  sufficiently  removed,  and 
the  possibility  of  irritating  a  very  mdolent  disease 
and  exciting  it  to  rapid  and  dangerous  growth,  must 
all  be  taken  into  account  in  concluding  to  attempt 
the  removal  of  malignant  disease  of  the  larynx 
through,  the  mouth. 

(2)  Suprathyroid  Laryngotomy  (subhyoid  pharyn- 
gotomy). — This  operation  has  been  performed  occa- 
sionally in  cases  where  the  malignant  growth  has 
been  situated  at  the  upper  opening  of  the  larynx,  par- 
ticularly in  connection  with  the  epiglottis.  Butlin, 
however,  is  strongly  of  opinion  that  all  growths 
occupying  the  sides  and  back  of  the  larynx  can  be 
more  thoroughly  exposed  and  removed  by  division 
of  the  thyroid  cartilage  (laryngo-fissure — thyrotomy) 
than  by  suprath3Toid  laryngotomy,  and  that  the 
epiglottis   can   be  better  dealt  with   by  thyrotomy. 

4—2 


52    Malignant  Disease  of  the  Larynx 

The  operation  of  suprathyroid  laryngotomy  is  carried 
out  by  making  a  transverse  incision  through  the 
thyro-hyoid  membrane  along  the  lower  border  of  the 
hyoid  bone;  the  incision  divides  the  skin,  superficial 
fascia,  inner  half  of  the  sterno-hyoid  and  thyro-hyoid 
muscles,  the  membrane  itself,  and  the  mucous  mem- 
brane between  the  base  of  the  tongue  and  the 
epiglottis. 

The  epiglottis  is  now  seized  and  brought  out 
through  the  wound,  and  the  growth  removed  in 
such  a  manner  as  appears  most  suitable  to  the 
individual  case.  The  length  of  the  incision  and  the 
structures  which  are  divided  vary  according  to  the 
size  and  situation  of  the  tumour. 

There  is  little  if  any  haemorrhage,  the  vessels 
wounded  being  few  in  number  and  insignificant  in 
size.  After  the  operation  the  wound  is  carefully 
closed  with  fine  silk  sutures,  and  healing  should  take 
place  by  first  intention. 

(3)  Infrathyroid  Laryngotomy.  —  This  operation 
has  been  advocated  and  practised  for  the  removal  of 
growths  on  the  under  aspect  of  the  cords,  or  actually 
below  the  cords  (subglottic  growths).  Thyrotomy, 
however,  with  a  downward  extension  of  the  incision 
gives  more  room  and  a  better  chance  of  thorough 
removal  of  the  disease,  and  is  therefore  to  be  pre- 
ferred. 

By  this  means  Butlin  has  removed  tumours  an 
inch  below  the  vocal  cords,  and  for  those  which  lie 
immediately  below  the  cords  there  is  no  necessity  to 
practise  even  a  modification  of  the  ordinary  operation 
of  thyrotomy. 


Carcinoma  of  the  Larynx  53 

Irlfrathyroid  laryngotomy  is  performed  in  just  the 
same  way  as  laryngotomy,  but  the  incision  is  made 
transversely,  and  not  vertically,  as  in  laryngotomy. 
The  only  vessel  likely  to  give  rise  to  any  haemorrhage 
is  the  crico-thyroid  artery,  and,  if  cut,  its  ends  should 
be  secured  before  incising  the  crico-thyroid  mem- 
brane. 

(4)  Thyrotomy  or  Laryngo-fissure  has,  during 
the  last  fifteen  years,  been  performed  much  more 
frequently  than  any  other  operation  for  the  removal 
of  malignant  disease  of  the  larynx  in  this  country, 
and  has  steadily  gained  in  repute  during  that  period. 
It  is  particularly  applicable  to  sarcomas  and  carci- 
nomas of  intrinsic  origin.  As  Butlin  (in  conjunction 
with  Semon)  has  been  mainly  responsible  for  the 
introduction  of  it  into  this  country  in  cases  of 
malignant  disease,  and  for  such  modifications  in  the 
after-treatment  as  have  served  to  render  it  far  less 
fatal  than  it  used  to  be,  a  description  of  Butlin's 
method  of  performing  the  operation  is  herewith 
given. 

The  patient,  having  been  placed  in  a  good  light, 
chloroform  or  A.C.E.  mixture  is  administered  ; 
ether,  if  possible,  should  be  avoided,  as  it  excites 
the  secretion  of  much  mucus  and  saliva,  which 
obscure  the  parts  to  be  removed.  The  patient  being 
anaesthetized,  the  shoulders  and  neck  are  raised  and 
the  head  is  thrown  back.  The  skin  is  prepared  as 
for  any  other  operation.  An  incision  is  made  from 
the  hyoid  bone  accurately  in  the  middle  line  down 
almost  to  the  sternum,  and  the  structures  are  divided 
right  down  to  the  thyroid  cartilage  and  the  trachea, 


54    Malignant  Disease  of  the  Larynx 

including  generally  the  isthmus  of  the  thyroid  gland. 
The  vessels,  mostly  veins,  are  clamped.  The  trachea 
is  then  freely  opened  below  the  cricoid  cartilage,  and 
a  Hahn's  compressed  sponge  cannula  inserted."  It 
is  of  the  greatest  importance  that  the  compressed 
sponge  be  rendered  thoroughly  aseptic  before  it  is 
used. 

Thus  ends  the  first  part  of  the  operation,  for  an 
interval  of  ten  to  twelve  minutes  must  now  be 
allowed  before  the  larynx  is  opened,  in  order  to 
permit  of  the  expansion  of  the  compressed  sponge, 
the  object  of  which  is  to  occlude  the  lower  air- 
passages  and  prevent  the  entry  of  any  blood  or  other 
liquids  therein  when  the  lar3nx  is  opened.  There 
should  be  no  undue  haste  to  open  the  larynx  after 
tracheotomy  has  been  performed,  the  full  ten  minutes' 
interval  being  carefully  observed.  During  this  interval 
the   clamped  vessels  should   be   ligatured,   and   the 

*  There  is  a  tendency  at  the  present  time  to  dispense  with 
the  tampon  cannulae,  Kocher  lately  having  renounced  them 
altogether.  If,  however,  as  is  still  usual,  a  tampon  cannula  be 
used,  that  of  Hahn  is  to  be  preferred.  Butlin  gives  the  fol- 
lowing reasons  for  his  preference  of  this  tube  :  (i)  It  consists  of 
an  inner  and  outer  tube,  the  former  of  which  is  the  longer,  and 
projects  about  ^  inch  in  front  of  the  shield,  thus  rendering  the 
entrance  of  blood  less  likely.  (2)  The  outer  tube  is  partly 
covered  with  a  layer  of  compressed  sponge  previously  soaked 
in  iodoform  and  ether  (i  in  7).  (3)  About  ten  minutes  after  the 
introduction  of  the  tube  the  sponge  swells  up  from  absorption 
of  moisture  and  effectually  tampons  the  trachea,  thus  prevent- 
ing the  entrance  of  liquids.  This  arrangement  of  sponge  holds 
the  tube  steadier  than  the  indiarubber  bag  of  Trendelenburg's 
cannula,  which  latter,  moreover,  is  liable  to  become  slippery,  to 
leak,  or  even  burst,  during  the  progress  of  the  operation. 


Carcinoma  of  the  Larynx  55 

upper   part   of    the   wound    be    kept    covered   with 
gauze. 

At  the  expiration  of  the  ten  or  twelve  minutes 
the  thyroid  cartilage,  which  has  been  exposed  by  the 
preliminary  median  incision,  is  split  in  the  middle 
line  from  below  upwards.  This  is  important ;  for, 
as  the  cartilage  is  generally  calcified  and  requires  the 
use  of  bone  forceps,  the  inner  blade  of  the  forceps 
working  from  above  downwards  may  slit  or  detach 
one  of  the  vocal  cords  at  its  anterior  extremity.  If 
the  growth  proves  after  all  to  be  innocent,  and  does 
not  call  for  removal  of  any  part  of  the  vocal  cords, 
such  an  accident  results  almost  certainly  in  per- 
manent injury  to  the  voice.  In  patients  of  such  an 
age  as  those  in  whom  these  operations  are  performed 
it  is  not  unusual  to  find  the  thyroid  cartilage  ossified, 
and  this  condition  may  necessitate  the  use  of  a  saw 
for  its  division.*  The  crico-thyroid  membrane  is 
divided  down  to  the  cricoid  cartilage,  and  the  in- 
cision is  carried  upwards  beyond  the  level  of  the 
upper  border  of  the  thyroid  cartilage  in  order  to  gain 
as  much  space  as  possible,  but  it  is  desirable  not 
to  interfere  with   the  attachment  of  the  epiglottis, 

■^  Quite  recently  Mr.  Waggett,  of  London,  has  invented  a  pair 
of  shears  for  division  of  the  thyroid  cartilage  without  damage  to 
the  vocal  cords.  The  shears  have  strong  thick  blades  set  at  a 
right  angle  to  the  handles.  The  inner  blade  is  inserted  below 
through  an  incision  in  the  crico-thyroid  membrane.  The  outer 
blade  is  provided  with  a  projecting  tooth  at  its  distal  end.  This 
tooth  enables  the  surgeon  to  fix  the  blade  exactly  in  the  mid- 
line of  the  larynx  before  cutting  through  the  thyroid  cartilage. 
The  instrument  has  been  used  in  several  cases  of  thyrotoniy, 
and  found  to  be  very  efficient. 


56    Malignant  Disease  of  the  Larynx 

unless  the  situation  of  the  growth  makes  this  im- 
perative. 

The  two  alae  of  the  thyroid  cartilage  are  then  held 
widely  apart  by  means  of  silk  threads  passed  through 
each.  The  interior  of  the  larynx  is  sponged  out  dry, 
and  is  then  brushed  with  a  20  per  cent,  solution  of 
cocaine,  the  effect  of  which  is  to  cause  contraction 
of  the  small  vessels  and  lessening  of  any  haemor- 
rhage, and  also  a  diminution  of  the  sensibility  of  the 
parts — a  very  important  point  if  the  patient  is  not 
deeply  under  the  influence  of  the  anaesthetic  used. 

At  this  stage  of  the  operation  the  use  of  a  frontal 
mirror  and  a  good  source  of  light  in  order  to  illu- 
minate the  interior  of  the  larynx  and  define  the 
extent  and  exact  situation  of  the  disease  will  be  found 
of  great  advantage. 

Two  elliptical  incisions  carried  down  to  the  peri- 
chondrium and  surrounding  the  diseased  tissues,  and 
including  more  than  half  an  inch  of  the  surrounding 
apparently  healthy  tissues,  without  respect  to  the 
after-use  of  the  voice  or  any  other  consideration 
except  the  complete  removal  of  the  disease,  are  made 
with  knife  or  scissors.  The  included  area  is  cut  out 
right  down  to  the  cartilage,  which  is  laid  bare,  and 
finally  scraped  absolutely  bare  with  a  Volkmann's 
sharp  spoon.  The  cavity  left  is  plugged  with  iodo- 
form gauze,  upon  which  pressure  is  made  for  two  or 
three  minutes.  By  this  means  the  bleeding,  which 
is  never  serious,  is  checked.  The  gauze  is  then 
removed  and  the  surface  dusted  with  powdered  iodo- 
form. 

Neither  Butiin  nor  Semon  has  used  the  galvano- 


Carcinoma  of  the  Larynx  57 

cautery  to  the  interior  of  the  larynx  for  some  years 
past,  and  neither  has  ever  seen  bleeding  which  could 
occasion  the  least  anxiety.  If  a  small  vessel  spouts 
it  should  be  ligatured  with  the  finest  catgut  or  silk. 

The  alae  of  the  thyroid  cartilage  are  now  brought 
together  with  a  couple  of  silk  or  silver  sutures,  and 
are  brought  into  as  close  apposition  as  possible.  The 
Hahn's  tube  is  removed,  and  the  edges  of  the  wound 
in  the  soft  parts  brought  together  and  sutured,  except 
at  the  lower  part  where  the  tube  was  inserted.  It  is 
infinitely  safer  to  leave  this  part  open,  so  that  there 
may  be  a  ready  exit  for  the  escape  of  blood  and  other 
liquids  from  the  larynx  and  trachea,  and  in  order  to 
guard  against  cellular  infiltration  beneath  the  skin. 

In  order  to  hasten  convalescence,  some*  operators 
have  lately  closed  the  entire  wound.  It  is,  however, 
a  proceeding  to  be  condemned,  as  it  aims  solely  at 
shortening  what  is  really  a  very  short  after-treatment, 
and  does  so  with  decided  risk  to  the  patient. 

Butlin  has  devoted  considerable  attention  to  the 
after-treatment  of  these  operations,  which  is  now 
conducted  on  the   following  lines  :    Hahn's  tube  is 

*  Moure  {Journal  of  Laryjtgology ,  December,  1903),  after 
thyrotomy,  sutures  completely  the  laryngo-tracheal  opening 
from  top  to  bottom— that  is  to  say,  he  omits  all  kinds  of 
cannula.  For  prudence'  sake  he  leaves  unsutured  a  spot  cor- 
responding to  the  tracheal  opening,  but  brings  the  lips  of  the 
tracheal  aperture  together.  An  assistant  has  to  remain  close  at 
hand  for  twenty-four  to  forty-eight  hours  in  case  the  cannula 
has  to  be  suddenly  inserted.  Moure  claims  that  this  closure 
hastens  cure  and  lessens  materially  the  tendency  to  broncho- 
pneumonia. He  has  had  no  death  from  the  operation  as  he 
practises  it. 


58    Malignant  Disease  of  the  Larynx 

removed  as  soon  as  the  operation  is  finished,  and  no 
tube  of  any  sort  is  employed  in  its  place.  A  piece 
of  cyanide  or  iodoform  gauze  is  placed  over  the 
wound,  and  secured  by  means  of  a  single  turn  of 
bandage.  The  piece  of  gauze  is  changed  by  the 
nurse  as  frequently  as  it  becomes  soiled.  The  patient 
is  placed  on  his  side  with  only  a  single  flat  pillow 
for  the  head,  that  side  being  lowermost  which  corre- 
sponds to  the  half  of  the  larynx  operated  upon.  In 
this  position  all  liquids  tend  to  pass  out  of  the  air- 
passages,  especially  through  the  external  wound. 

Formerly  the  sponge  cannula  was  left  in  the 
trachea  for  the  first  twenty-four  or  forty-eight  hours, 
in  case  any  secondary  haemorrhage  occurred,  and  the 
interior  of  the  larynx  was  packed  with  strips  of  iodo- 
form gauze.  After  the  Hahn's  tube  was  removed,  an 
ordinary  tracheotomy  tube  was  inserted.  There  is 
no  doubt  that  the  compressed  sponge  surrounding 
Hahn's  tube  has  in  some  cases  of  thyrotomy,  where 
it  has  been  retained  from  twenty-four  to  forty-eight 
hours,  acted  as  a  source  of  septic  infection.  Again, 
the  strips  of  iodoform  gauze  packed  into  the  larynx 
in  the  earlier  operations  acted  as  irritants  to  that 
organ,  becoming  soaked  in  mucus  and  saliva,  and 
in  some  cases  getting  displaced,  hanging  down  the 
trachea  and  acting  as  foreign  bodies.  Hahn's  tube 
and  the  iodoform  gauze  plugging  were  therefore 
entirely  discarded  by  Butlin,  and  with  most  excellent 
results. 

Within  four  or  five  hours  of  the  operation  an 
attempt  may  be  made  to  swallow.  The  patient  is 
made  to  lean  well  over  to  the  opposite  side  to  that 


Carcinoma  of  the  Larynx  59 

operated  on,  and  the  dressing  is  taken  off  the  wound,, 
beneath  which  a  basin  is  placed.  Cold  sterilized 
water  is  drunk  out  of  a  feeder  placed  in  the  corner 
of  the  mouth.  If  this  experiment  is  successful,  all 
the  water  passes  down  into  the  stomach  ;  if  it  is  only 
partially  successful,  some  escapes  into  the  larynx. 
The  posture,  however,  of  the  patient  insures  that  it 
runs  out  through  the  wound  and  does  not  enter  the 
air-passages.  If  there  is  any  fear  of  collapse,  and 
the  patient  be  feeble  or  very  old,  brandy  and  beef- 
tea  may  be  administered  by  the  rectum.  As  soon  as 
water  can  be  swallowed  with  ease,  milk,  beef-tea,  and 
other  liquids  may  be  drunk,  for  the  fear  of  '  degluti- 
tion pneumonia  '  {Schluckpneumonie)  is  practically  at 
an  end.  The  wound  is  generally  closed  within  ten 
or  twelve  days  of  the  operation,  and  the  patient  is 
rarely  confined  to  the  house  for  more  than  ten  days. 
This  description  applies  only  to  those  cases  in  which 
the  disease  is  limited  to  the  soft  parts  of  the  larynx 
and  is  of  small  extent. 

In  other  cases  the  operation  may  need  to  be 
modified,  even  to  the  extent  of  removal  of  a  large 
part,  or  even  the  whole,  of  the  framework  of  the 
larynx.  The  operation  may  thus  pass  into  that  of  a 
more  or  less  atypical  partial  laryngectomy,  and  as 
almost  invariably  the  amount  of  disease  found  to  be 
present  after  opening  the  larynx  is  greater  than  the 
laryngoscopic  picture  has  shown  it  to  be,  it  should 
be  a  rule  before  undertaking  the  operation  of  thyro- 
tomy  for  malignant  disease  of  the  larynx  to  obtain 
the  patient's  consent  to  the  performance  of  a  more 
extensive  and  graver  operation  if  it  is  found  necessary. 


6o    Malignant  Disease  of  the  Larynx 

Although  the  operation  in  some  cases  ends  in  a 
more  or  less  atypical  partial  laryngectomy,  yet  the 
removal  of  insignificant  portions  of  cartilage  from 
the  interior  of  the  larynx,  together  with  the  diseased 
soft  parts,  should  not  permit  the  operation  being 
classified  as  other  than  thyrotomy.  Again,  the 
operator  may  find  on  examination  that  the  patient  is 
not  likely  to  be  benefited  by  an  attempt  to  remove  the 
disease,  and  may  then  decide  to  abandon  the  opera- 
tion, contenting  himself,  perhaps,  with  introducing 
an  ordinary  tracheotomy  tube  for  permanent  wear. 

Iodoform  powder  may  be  insufflated  into  the 
larynx  during  the  first  days  after  the  operation 
through  the  mouth  by  means  of  an  insufflator  with  a 
bent  nozzle.  Subsequently  careful  periodical  exami- 
nations of  the  larynx  should  be  made.  It  is  not 
infrequent  to  find  a  mass  of  granulation  tissue  in  the 
anterior  commissure  after  thyrotomy*  for  malignant 
disease.  To  those  not  acquainted  with  this  fact,  this 
tissue  is  very  likely  to  be  mistaken  for  a  recurrence  of 
the  growth.  In  such  cases  the  tissue  should  be  left 
alone  at  first,  and  later  a  piece  removed  by  endo- 
laryngeal  operation  and  submitted  to  microscopic 
examination.  Almost  invariably  this  tissue  is  found 
to  be  innocent  in  nature,  and  after  the  removal  of  a 
piece  it  usually  shrinks,  and  finally  disappears. 

*  It  has  been  recently  suggested  that  this  granulation  tissue 
is  found  in  the  line  of  the  sutures  uniting  the  two  halves  of  the 
thyroid  cartilage,  and  some  operators  pass  their  sutures  through 
only  part  of  the  substance  of  the  cartilage,  so  as  to  obviate  any 
irritative  action  of  the  sutures  if  passing  through  the  cartilage 
and  thus  into  the  interior  of  the  larynx. 


Carcinoma  of  the  Larynx  6i 

(5)  Excision  or  Extirpation  of  the  Larynx, 
Complete  and  Partial  (Total  and  Hemi  Laryngec- 
tomy).—  The  first  complete  excision  of  the  larynx 
was  performed  by  Dr.  Patrick  H.  Watson  in  1866. 
The  patient,  a  male,  aged  thirty-six,  was  suffering 
from  severe  syphilitic  stenosis  of  the  larynx,  and  sur- 
vived the  operation  three  weeks.  Billroth,  in  the  year 
1873,  performed  the  first  complete  extirpation  of  the 
larynx  for  carcinoma  of  that  organ,  death  taking 
place  seven  months  later  from  recurrence.  In  1878 
the  same  operator  excised  half  the  larynx  for  the 
same  disease. 

Since  that  date  a  large  number  of  extirpations  has 
been  performed,  so  that  Sendziak  was  able  years  ago 
to  put  together  188  cases  of  total  removal  of  the 
larynx  for  malignant  disease,  and  might  have  used 
a  larger  number  had  the  reports  been  sufficiently 
complete  for  his  purpose.  But  while  thyrotomy  has 
been  steadily  growing  in  favour  during  the  last  ten  to 
fifteen  years,  total  extirpation  has  been  decidedly  less 
frequently  practised. 

Again,  thyrotomy  is  the  operation  of  the  English 
school,  while  extirpation  is  largely  practised  by  the 
German  School  of  Surgery.  Between  1881  and  1888, 
according  to  Sendziak,  no  total  extirpations  were 
performed ;  between  1888  and  1894  only  47. 

Operation  of  Total  Laryngectomy. 

Tracheotomy. — The  trachea  may  be  opened  (a) 
either  some  time  previously,  {b)  at  the  time  of  opera- 
tion, (c)  or  be  dispensed  with  altogether.     • 


62     Malignant  Disease  of  the  Larynx 

In  patients  suffering  from  long-continued  dyspnoea 
it  is  probably  an  advantage  to  perform  tracheotomy 
at  least  a  week  before  laryngectomy.  The  patient 
becomes  accustomed  to  breathing  through  the  arti- 
ficial apparatus,  and  the  lungs  become  less  engorged, 
consequently  broncho-pneumonia  is  less  likely  to 
ensue.  Moreover,  less  time  will  be  taken  up  by  the 
operation,  and  no  blood  will  enter  the  trachea  from 
this  source.  A  low  tracheotomy  is  preferable  to  a 
high  one,  as  the  latter  may  be  too  near  the  seat  of 
disease. 

There  is  a  decided  tendency  for  operators  at  the 
present  time  to  dispense  with  tracheotomy  altogether. 
In  Jacobson's  '  Operations  of  Surgery,'  vol.  i.,  p.  513, 
the  following  statement  of  Professor  Keen  is  given : 

*  In  the  case  which  is  the  basis  of  this  paper  (a 
patient  aged  thirty-nine.  Thyrotomy,  May,  i8g8  ; 
recurrence  in  September.  Complete  laryngectom}', 
October.  Recovery),  I  did  tracheotomy  at  the 
time  of  operation,  but  removed  the  tube  at  the 
termination  of  the  laryngectomy,  immediately  closed 
the  wound  in  the  trachea,  and  obtained  absolute 
primary  union.  In  any  future  case  I  am  strongly  of 
opinion  that  it  will  be  better  to  omit  tracheotomy 
altogether.  As  I  shall  show,  it  is  not,  in  my  opinion, 
needful,  and  by  omitting  it  we  shall  eliminate  one 
cause  of  septic  pneumonia.'  And,  again,  later  :  '  A 
further  improvement  can  be  made  in  the  technique — 
viz.,  the  omission  of  an}-,  even  a  temporary,  tracheo- 
tomy. In  my  next  case,  after  dissecting  the  soft 
parts  from  the  larynx  and  upper  trachea  back  to  the 
oesophagus  on  both  sides,  I  shall  place  the  patient  in 


Carcinoma  of  the  Larynx  67, 

the  Trendelenburg  position,  and  deepen  the  narcosis 
to  a  sHght  extent.  I  shall  then  divide  the  trachea 
transversely,  and  by  three  sutures,  one  in  the  mid- 
line and  one  on  each  side,  I  shall  quickly  attach  the 
tracheal  stump  to  the  skin.  Then  I  shall  introduce 
the  ordinary  tracheotomy  tube  into  the  open  end  of 
the  trachea  instead  of  through  a  tracheotomy  wound, 
and  continue  the  anaesthetic  through  the  tube.  In 
order  not  to  embarrass  the  operator,  the  flange  of  the 
tracheotomy  tube  should  only  project  at  the  sides,  as 
the  usual  wide  upper  border  of  the  flange  would 
interfere  with  access  to  the  parts  at  the  beginning  of 
removal  of  the  larynx.' 

The  position  of  the  patient  is  a  debatable  one.  If 
the  surgeon  decides  to  perform  the  operation  by 
cutting  from  above  downwards,  then  the  position  of 
the  patient  will  be  the  same  as  for  thyrotomy  ;  if 
from  below  upwards,  Trendelenburg's  position  must 
be  employed. 

Removal  by  cutting  from  above  downwards  is  the 
more  usual  procedure,  and  has  the  advantage  of 
leaving  the  division  of  the  trachea  to  the  last,  thus 
avoiding  the  risk  of  the  escape  of  blood  and  lotions 
into  the  trachea.  It  also  avoids  the  need  of  using  a 
tampon  cannula. 

If  no  tracheotomy  is  performed,  either  previously 
or  at  the  time  of  operation,  the  median  incision  being- 
made,  the  trachea  is  first  isolated  and  divided,  and  a 
large  tube  inserted. 

Professor  Keen  strongly  advocates  Trendelenburg's 
position  in  this  and  all  operations  on  the  upper  air- 
passages. 


64    Malignant  Disease  of  the  Larynx 

The  patient  should  be  prepared  in  the  usual  way 
as  regards  the  skin,  and  particular  attention  should 
be  paid  to  the  teeth,  nose,  and  mouth  for  three  days 
prior  to  operation. 

A.C.E.  mixture  is  the  anaesthetic  generally  used, 
and  it  should,  when  feasible,  be  given  for  as  long  as 
possible  by  the  mouth,  and  later  on  when  the  trachea 
is  severed  through  the  tracheotomy  tube  by  tubing 
attached  to  the  inner  tube. 

If  the  operation  be  begun  from  above  downwards, 
a  vertical  incision  is  made  from  the  lower  border  of 
the  hyoid  bone  exactly  in  the  middle  line  down  to 
the  level  of  the  second  or  third  ring  of  the  trachea. 
This  vertical  incision  is  usually  supplemented  by  a 
transverse  incision  across  the  thyro-hyoid  membrane 
just  below  the  great  cornua  of  the  hyoid  bone,  or 
across  the  thyroid  cartilage,  and  passing  outwards  to 
the  sterno-mastoid  muscles.  The  vertical  incision, 
as  in  thyrotomy,  should  go  down  to  the  thyroid  and 
cricoid  cartilages  and  trachea. 

After  securing  the  superior  and  inferior  thyroid 
arteries,  the  fascia  in  the  mid-line  must  be  well 
divided,  and  the  soft  parts  turned  back  from  the 
cartilages  and  trachea  with  a  broad  periosteal  elevator 
or  rugine  to  a  level  with  the  middle  of  the  junction 
of  the  larynx  and  pharynx. 

In  some  cases  the  flaps  have  to  be  turned  back 
even  further,  and  the  sterno-mastoid  muscles  partly 
divided.  This  is  not  necessary,  however,  unless  the 
disease  has  extended  into  the  surrounding  struc- 
tures, or  the  glands  are  to  be  removed  at  the  same 
time. 


Carcinoma  of  the  Larynx  65 

It  is  better  to  open  the  larynx  by  carefully  dividing 
the  thyroid  cartilage  in  the  mid-line  before  deter- 
mining the  extent  of  the  operation,  although  some 
operators  object  to  the  practice  on  account  of  the 
greater  difficulty  afterwards  in  removing  the  larynx. 
But  it  is  so  important  to  be  certain  of  the  limits  of 
the  disease  before  proceeding  to  perform  extirpation 
that  this  consideration  outweighs  any  disadvantages 
which  arise  from  the  splitting  of  the  thyroid  cartilage. 
If  the  disease  is  quite  limited  to  the  soft  parts,  yet  of 
large  extent,  the  operation  maybe  limited  to  the  very 
free  removal  of  the  affected  tissues,  with  a  wide  area 
of  the  surrounding  healthy  structures.  And  this  may 
do  as  much  for  the  patient  as  would  be  accomplished 
by  the  removal  of  any  part  of  the  laryngeal  frame- 
work. If  the  disease  is  limited  to  one-half  of  the 
larynx,  the  operation  of  partial  excision  may  be 
carried  out  and  the  healthy  side  of  the  larynx  be 
left.  Again,  in  cases  in  which  it  is  found  to  be 
necessary  to  remove  the  entire  larynx,  the  operator 
may  judge  from  his  inspection  of  the  disease  whether 
the  epiglottis  and  cricoid  cartilage  should  also  be 
removed. 

Before  proceeding  to  the  actual  removal  of  the 
larynx,  the  sterno-hyoid,  sterno-thyroid,  and  thyro- 
hyoid muscles  having  been  separated  and  turned  off 
the  thyroid  cartilage,  the  lateral  lobes  of  the  thyroid 
gland  must  be  carefully  separated  with  a  raspatory, 
and  the  soft  parts  at  the  sides  which  contain  the 
large  vessels  carefully  retracted,  and  the  larynx  alter- 
nately pulled  over  first  to  one  side  and  then  to  the 
other   so    that   the    attachments    of  the    constrictor 

5 


66    Malignant  Disease  of  the  Larynx 

muscles  to  the  thyroid  and  cricoid  cartilages  may  be 
divided.  For  this  purpose  it  is  important  to  employ 
curved  blunt-pointed  scissors  and  keep  very  close  to 
the  cartilages. 

The  actual  removal  of  the  larynx  is  now  proceeded 
with,  and  can  be  carried  out  either  from  below 
upwards  or  from  above  downwards,  according  to  the 
views  of  the  operator.  It  is  on  the  whole  preferable 
to  remove  the  larynx  from  above  downwards.  The 
thyro-hyoid  ligaments  and  membrane  are  divided, 
and  the  extralaryngeal  attachments  of  the  epiglottis* 
cut  through.  The  entire  larynx  is  now  held  well 
forwards  by  means  of  a  vulsellum  forceps,  and  the 
organ  is  separated  from  its  remaining  connections  to 
the  pharynx  and  oesophagus  at  first  laterally  and  then 
from  above  downwards. 

Especial  care  should  be  taken  to  keep  close  to  the 
larynx  in  order  to  avoid  wounding  the  large  vessels 
and  nerves  which  lie  beside  it;  and  if  the  cricoidt 
'cartilage  and  upper  rings  of  the  trachea  are  removed, 
the  same  care  should  be  exercised  to  avoid  opening 
the  oesophagus. 

When  or  as  the  trachea  is  divided,  two  ligatures 
should  be  passed  through  the  divided  upper  end  to 
prevent  the  trachea  slipping  down,  and  the  upper 
end  is  firmly  secured  to  the  skin  by  several  points  of 
interrupted  sutures. 

Finally,  three  to  four  deep  silver  sutures  are  passed 

■^  It  is  far  safer  to  always  remove  the  epiglottis  ;  it  is  of  no 
use  if  left,  and  may  be  the  seat  of  a  rapidly-recurring  growth. 

t  The  cricoid,  if  left,  interferes,  according  to  Hahn,  seriously 
with  deglutition. 


Carcinoma  of  the  Larynx  67 

beneath  the  uppermost  ring  and  attach  the  trachea 
to  the  skin,  and  a  further  set  of  fine  superficial 
sutures  unite  the  mucous  membrane  of  the  trachea 
to  the  cut  edge  of  the  skin. 

Some  operators  retain  Hahn's  tube  for  two  or 
more  days  after  the  operation ;  others  remove  it 
earher,  and  replace  it  with  an  ordinary  full-sized 
tracheotomy  tube  surrounded  with  iodoform  gauze, 
the  gauze  being  changed  daily  and  wrung  out  in 
I  in  20  carbolic  acid.  The  transverse  incision  should 
be  brought  together  at  the  ends  by  one  or  two 
sutures,  but  the  vertical  incision  should  be  left  open 
for  drainage,  the  wound  being  tamponaded  with 
iodoform  gauze. 

After-treatment. — The  dressings  should  not  be 
changed  too  frequently,  but  at  each  dressing  care- 
ful cleansing  of  the  large  wound  must  be  carried 
out. 

The  patient  is  fed  during  some  days  through  an 
indiarubber  tube,  which  may  either  be  permanently 
retained  as  long  as  it  is  requisite  or  may  be  passed 
for  each  feeding.  At  the  end  of  four  or  five  days  an 
attempt  is  made  to  swallow.  The  same  posture  and 
precautions  should  be  adopted  as  have  been  described 
in  the  operation  for  thyrotomy,  but  soft  solids  such 
as  jelly  are  generally  more  easily  swallowed  than 
liquids. 

The  temperature  of  the  room  must  be  kept  at  from 
65°  to  70°,  and  the  inspired  air  charged  wdth  anti- 
septic vapours. 

The  sutures  connecting  the  trachea  with  the  skin 
should  be  removed  at  as  early  a  date  as  possible  ; 

5—2 


68    Malignant  Disease  of  the  Larynx 

they  very  soon  tend  to  become  buried,  and  are  corre- 
spondingly difficult  to  find  and  remove. 

The  tracheotomy  tube  must  be  kept  exceedingly 
clean. 


Partial  Extirpation  of  the  Larynx  :  Hemi- 
laryngectomy. 

This  operation,  which  consists  in  the  removal  of 
one-half  of  the  larynx,  is  in  details  practically  identical 
with  complete  laryngectomy.  The  vertical  incision 
is  the  same,  but  the  transverse  incision  is  made  only 
on  the  diseased  side. 

The  larynx  having  been  exposed  by  separating  the 
soft  parts  on  its  outer  surface  with  elevator  or  rugine, 
the  thyroid  cartilage  is  carefully  divided  in  the  mid- 
line either  by  cutting  bone  forceps  or  saw,  and  the 
extent  of  the  disease  ascertained.  If  found  to  be 
limited  to  one-half  of  the  larynx,  and  yet  too  exten- 
sive for  removal  by  thyrotomy,  excision  of  the  affected 
half  is  proceeded  with. 

The  soft  parts  having  been  carefully  raised  from 
the  affected  half,  the  attachments  to  the  pharynx 
are  separated,  the  thyro-hyoid  and  crico-thyroid 
membranes  cut  as  close  as  possible  to  the  margin  of 
the  thyroid  cartilage,  and  the  superior  cornu  of  the 
latter  divided  at  its  base  with  bone  forceps. 

The  aryepiglottic  fold  is  now  divided  on  the 
affected  side  close  to  the  cartilage  of  Wrisberg ;  in 
some  cases  one-half  of  the  epiglottis  is  split  and 
removed. 

The  cricoid  cartilage  is  now  divided  in  the  mid- 


Carcinoma  of  the  Larynx  69 

line  both  in  front  and  behind,  and  the  divided  half 
of  the  larynx  detached  from  the  first  ring  of  the 
trachea  and  thus  removed. 

In  partial  excision  of  the  larynx  for  intrinsic 
disease  there  is  usually  no  need  to  remove  one-half 
of  the  cricoid  cartilage. 

The  after-treatment  is  the  same  as  in  total  removal 
of  the  larynx,  but  it  will  be  found  that  the  patient  is 
able  to  dispense  with  the  cannula  earlier,  and  to  take 
food  by  the  mouth  a  few  days  after  operation. 

Results  of  Operation. 

Mortality  due  to  the  Operation. — The  mortality 
varies  enormously  according  to  the  operation  which  is 
performed,  and  particularly  so  according  to  whether  it 
is  performed  for  extrinsic  or  intrinsic  disease  of  the 
larynx.  Among  the  many  publications  which  have 
appeared  in  recent  times,  that  which  probably  contains 
the  largest  number  of  collected  cases  is  Sendziak's 
{loc.  cit.). 

The  material  has  been  obtained  from  both  private 
and  public  sources,  and  Sendziak  has  given  an 
immense  amount  of  labour  to  the  analysis  of  it.  He 
has  not,  however,  quite  grasped  the  importance  of 
a  separation  of  the  intrinsic  from  the  extrinsic  carci- 
nomas, and  apparently  has  not  realized  that  the 
practice  of  this  country  is  founded  upon  the  great 
difference  in  the  pathology  of  laryngeal  carcinoma 
according  as  it  originates  from  the  intrinsic  or  ex- 
trinsic parts  of  the  larynx.  Moreover,  he  has  not 
attached   sufficient  weight  io  the  marked  improve- 


/O    Malignant  Disease  of  the  Larynx 

ments  that  have  taken  place  during  the  last  ten  to 
fifteen  years. 

The  conclusions  at  which  Butlin  arrived  from  a 
study  of  the  disease,  and  the  operations  which  had 
been  performed  for  its  removal  in  1883  ('  Malignant 
Disease  of  the  Larynx ')  and  in  1887,  when  the  first 
edition  of  his  book,  '  The  Operative  Surgery  of 
Malignant  Disease,'  was  published,  were  so  gloomy 
that  there  seemed  to  him  at  that  time  to  be  scarcely 
justification  for  the  performance  of  a  radical  operation 
for  carcinoma.  Scarcely  a  single  case  had  been 
cured  by  partial  extirpation,  and  the  operation  was 
highly  dangerous  to  life  ;  while  the  mortality  conse- 
quent on  complete  extirpation  of  the  larynx  was 
extremely  large,  and  the  successes  surprisingly  small. 
Moreover,  the  condition  of  the  patient  after  complete 
extirpation  of  the  larynx  was  far  from  enviable. 

Several  circumstances,  however,  seemed  to  justify 
further  experiment.  In  the  first  place,  the  mortality 
from  partial  resection  of  the  larynx  had  not  been 
extremely  large,  and  it  left  the  patient  in  a  suffi- 
ciently comfortable  condition.  In  the  second  place, 
an  exhaustive  study  of  the  pathology  of  the  disease 
led  Butlin  to  the  conclusion  that  Krishaber's  division 
of  carcinoma  of  the  larynx  into  those  of  intrinsic  and 
those  of  extrinsic  origin  was  of  the  greatest  im- 
portance and  value  from  a  pathological  point  of 
view.  On  the  strength  of  this  view,  he  suggested 
that  '  in  the  immediate  future  extirpation  of  the 
larynx  for  carcinoma  should  be  practised  only  for 
intrinsic  carcinoma  which  is  still  limited  to  the 
larynx.' 


Carcinoma  of  the  Larynx  71 

Sir  Felix  Semon  accepted  this  suggestion,  and  he 
and  Buthn  have  been  intimately  associated  ever  since 
that  time  in  working  out  to  a  successful  issue  the 
treatment  of  intrinsic  carcinoma  of  the  larynx  by 
operation.  The  first  case  which  seemed  to  Semon 
suitable  for  operation  was  treated  by  Hahn,  of 
Berlin  ;  the  second  case  by  Butlin  ;  and  many  cases 
since  then  by  Semon,  Butlin,  and  other  English 
laryngologists. 

The  nature  of  the  operation  in  the  two  first  cases 
was  partial  resection  of  the  larynx.  But  almost  all 
the  later  operations  have  consisted,  as  far  as  Semon 
and  Butlin  are  concerned,  in  opening  the  larynx  and 
freely  excising  the  disease  together  with  a  wide  area 
of  the  surrounding  and  apparently  healthy  tissues, 
so  much  so  that  the  operation  of  thyrotomy  is  now 
looked  upon  as  the  English  operation  for  carcinoma 
of  the  larynx :  and  Sendziak  said  in  1897  that 
Butlin  personally  had  performed  one-fifth  of  all  the 
thyrotomies  for  cancer  which  were  up  to  that  date 
on  record  in  medical  literature. 

The  reasons  in  favour  of  the  limitation  of  the 
operation  to  thyrotomy  are  :  the  very  small  liability 
of  the  disease  to  infiltrate  the  cartilage  of  the 
larynx,  whether  it  is  in  a  state  of  calcification  or 
not  ;  the  similarity  of  the  course  of  the  disease 
to  cancer  of  the  lip  ;  and  the  great  improvement 
which  has  been  made  in  the  early  diagnosis  of  the 
disease,  which  is  very  greatly  due  to  the  work  of 
Semon. 

It  is  sincerely  to  be  hoped  that  the  results  to  be 
described  will  tend  to  further  popularize  an  operation 


72     Malignant  Disease  of  the  Larynx 

which,  when   appHed   to  suitable  cases,   is  without 
doubt  marvellously  successful. 

Sendziak  reported  g  deaths  in  92  thyrotomies 
performed  for  cancer,  4  of  which  occurred  from 
pulmonary  troubles,  3  from  various  forms  of  septic 
infection,  i  from  failure  of  the  heart,  and  i  from 
syncope.  The  greater  number  of  these  operations 
were  naturally  performed  for  carcinoma  of  intrinsic 
origin,  but  the  list  includes  operations  for  extrinsic 
carcinoma ;  and  as  these  operations  are  decidedly 
more  dangerous  to  life  than  those  which  are  per- 
formed for  intrinsic  carcinoma,  the  mortality  is  b}' 
no  means  high. 

Up  to  the  end  of  July,  i8g6,  Butlin  and  Semon 
had  perfomed  17  thyrotomies  (on  16  patients)  for 
intrinsic  carcinoma  with  2  deaths,  i  due  to  sepsis, 
the  other  to  bronchitis  ;  so  that  at  first  sight  their 
mortality  seems  larger  than  that  of  Sendziak's  series 
of  cases.  But  since  August,  1896,  neither  of  them 
has  lost  a  patient  from  the  operation  ;  Butlin 's  last 
fatal  case  being  in  1889,  and  Semon's  in  1894,  from 
bronchitis,  which  was  present  before  the  operation. 
The  number  of  thyrotomies  Semon  has  performed 
since  July,  1896,  up  to  the  present  time  for  un- 
doubted intrinsic  carcinoma  of  the  larynx  amounts 
to  16 ;  in  none  of  these  has  death  followed  the 
operation. 

Butlin's  results  are  similar,  so  that  Butlin  and 
Semon  can  now  lay  claim  to  a  long  series  of  cases 
of  thyrotomy  for  intrinsic  carcinoma  unbroken  by  a 
single  fatal  result.  These  results  are  not  due  to  mere 
accident  or  good  fortune,  but  are  dependent  on  the 


Carcinoma  of  the  Larynx  'j;^ 

improvements  which  have  been  made,  both  in  the 
manner  of  performing  the  operation  and  even  more 
in  the  after-treatment.  The  immediate  removal  of 
Hahn's  tube,  the  frequent  changing  of  the  loose 
dressing  v^hich  covers  the  wound,  and  the  care  given 
to  the  proper  feeding  of  the  patient  have  effected  a 
most  salutary  change  in  the  prospect  of  recovery 
from  the  operation. 

Sendziak  looks  upon  a  mortality  of  lo  per  cent, 
as  marvellously  small,  but  it  is  quite  certain  that 
100  thyrotomies  ought  to  be  performed  at  the 
present  time  for  intrinsic  carcinoma,  with  a  mortality 
of  2  to  3,  perhaps  less  even  than  this. 

Of  partial  extirpations  of  the  larynx  for  carcinoma, 
Sendziak  has  collected  no  cases,  with  a  mortality 
from  the  operation  of  29,  equal,  therefore,  to  a  per- 
centage of  26*3.  This  percentage  is,  therefore,  nearly 
three  times  greater  than  that  of  the  thyrotomies 
collected  by  him. 

By  far  the  greater  number — i.e.,  22 — of  the  patients 
died  of  some  form  of  pulmonary  complication,  mostly 
septic,  6  of  collapse  or  cardiac  failure,  and  3  of 
haemorrhage.  Sendziak  is  of  opinion  that  this  per- 
centage proves  decidedly  that  partial  resection  of 
the  larynx  is  by  no  means  a  dangerous  operation  ! 
Surely  a  mortality  amounting  to  more  than  one- 
fourth  is  extremely  high  for  such  an  operation. 

Moreover,  a  careful  examination  of  his  tables, 
from  which  these  deductions  are  drawn,  points  to  a 
mortality  even  larger  than  he  has  stated ;  for  there 
appear  to  be  more  than  32  deaths,  and  his  own  list 
of  the  causes  of   death  makes  the  total  36,  unless 


74    Malignant  Disease  of  the  Larynx 

several  of  the  cases  are  placed  under  more  than  one 
heading. 

This  is  certainly  a  larger  mortality  than  ought  to 
follow  removal  of  not  more  than  one-half  of  the 
larynx.  Indeed,  the  far  smaller  mortality  in  the  last 
60  cases  (performed  during  or  since  1888)  than  in  the 
first  50  strongly  bears  out  this  more  favourable  view. 
The  mortality  percentage  is  almost  twice  as  large 
for  the  first  50  cases.  This  is  only  what  might  be 
expected  from  the  improved  methods  which  have 
been  employed,  not  only  in  carrying  out  the  opera- 
tion itself,  but  in  the  after-treatment  of  the  patient. 

Total  extirpation  of  the  larynx  is  an  extremely  dan- 
gerous operation.  Sendziak  notes  84  deaths  in  188 
cases,  and  places  the  mortality  at  44*7  per  cent. 
Naturally,  many  of  the  operations  were  far  more 
extensive  than  the  mere  removal  of  the  larynx, 
necessitating  far-reaching  dissections  into  the  neigh- 
bouring parts  and  removal  of  such  parts  as  the 
muscles,  lymphatic  glands,  and  pharynx.  But  as 
laryngectomies  in  the  future  are  not  likely  to  be  less 
extensive,  it  is  matter  of  doubt  whether  any  allow- 
ance should  be  made  on  this  account. 

But  here,  again,  the  later  mortality  is  much  less 
than  that  which  followed  the  earlier  operations.  For 
instance,  56  of  the  184  operations  were  performed 
during,  or  subsequent  to,  1888,  with  only  18  deaths. 
Had  the  mortality  been  equal  for  the  whole  series 
there  should  have  been  25  deaths,  so  that  the  relative 
mortality  is  very  much  lessened. 

Schmiegelow  {Ann.  des  M.  de  V Oreille,  du  Larynx, 
April,  1897),  mentions  50  cases  of  total  laryngectomy 


Carcinoma  of  the  Larynx  75 

for  carcinoma  performed  between  1890  and  1897; 
the  mortality  was  22  per  cent.,  half,  therefore,  that 
given  in  Sendziak's  tables. 

Still  later  Gluck,  at  the  meeting  of  the  British 
Medical  Association  held  at  Swansea,  1903,  has  given 
an  account  of  his  operations  and  their  remarkable 
and  brilliant  results.  He  performed  22  total  extir- 
pations with  only  i  death,  and  27  transverse  extir- 
pations of  the  larynx,  pharynx,  and  glands,  with  also 
only  I  death. 

Despite,  however,  every  care  and  skill  on  the  part 
of  the  operator,  it  is  probable  that  the  operation  of 
complete  laryngectomy  will  always  be  attended  by  a 
somewhat  high  rate  of  mortality.  There  must  always 
be  grave  danger  from  pulmonary  complications,  nearly 
40  of  the  patients  in  Sendziak's  tables  succumbing  to 
pneumonia,  usually  of  septic  origin.  Moreover,  no 
fewer  than  17  of  the  deaths  were  due  to  collapse 
and  paralysis  of  the  heart,  a  complication  possibly 
dependent  on  division  of  the  inhibitory  nerves  of 
the  heart  or  to  persistent  irritation  of  the  superior 
laryngeal  nerve. 

Cures  due  to  Operation. — In  this  matter  par- 
ticular attention  must  be  drawn  to  the  different  con- 
clusions which  are  to  be  derived  from  a  study  of 
Sendziak's  tables,  and  from  a  study  of  the  thyro- 
tomies  which  have  been  performed  during  the  last 
fifteen  years  in  this  country.  Sendziak  states  that  8 
out  of  the  total  number  of  85  were  alive  and  well  for 
more  than  three  years  subsequent  to  the  operation  of 
thyrotomy.  Eight,  however,  of  the  85  were  lost 
sight  of  soon  after  operation,  and  must  be  left  out  of 


76     Malignant  Disease  of  the  Larynx 

account,  leaving  the  total  at  "]"]  cases  with   8  cures, 
just  over  lo  per  cent. 

But  here,  again,  no  division  is  made  between  the 
operations  for  intrinsic  and  extrinsic  disease,  a  dis- 
tinction which  in  this  country  is  looked  upon  as  of 
vital  importance,  and  the  great  difference  in  the 
earlier  and  later  cases  is  not  emphasized. 

Thus,  6  of  the  8  successful  operations  were  per- 
formed during  or  after  i888,  and  the  6  contained 
three  of  Butlin's  and  one  of  Semon's,  so  that  these 
two  are  responsible  for  one-half  of  the  total  8  suc- 
cessful cases.  Reference  has  already  been  made  in 
treating  of  the  mortality  of  thyrotomy  for  malignant 
disease  to  the  number  of  cases  performed  by  Butlin 
and  Semon  up  to  July,  1896.  Their  results  since 
then  have  been  even  better.  For  instance,  Semon 
states  {British  Medical  Journal,  November  28,  1903): 
*  I  can  now  summarize  my  results  to  the  effect  that 
out  of  18  cases  of  undoubted  malignant  disease  of  the 
larynx  which  I  have  operated  upon  by  thyrotomy 
between  June  2,  1891,  and  July  29,  1902,  15 — that  is, 
85  per  cent. — were  permanently  cured.  Three  of 
these  patients  died  several  years  after  the  operation 
from  affections  altogether  unconnected  with  the 
original  disease,  one  six  years  after  from  an  acute 
abdominal  affection ;  the  second,  three  years  and  a 
quarter  after  the  operation  from  embolism  of  the 
heart  or  the  lungs ;  the  third,  four  years  after  opera- 
tion from  pneumonia.  The  remaining  12  are  now 
alive  and  well,  whilst  the  vocal  results,  with  the 
exception  of  a  few  cases  in  which  it  was  necessary  to 
remove  both  vocal  cords,  are  surprisingly  good.' 


Carcinoma  of  the  Larynx  "j^ 

It  is  difficult  to  lay  down  any  strict  rule  as  to  the 
period  that  should  elapse  subsequent  to  operation  for 
the  term  '  cured  '  to  be  used.  In  Sendziak's  work 
all  cases  under  three  years  from  operation  are  spoken 
of  as  '  relative  cures,'  and  all  cases  free  from  disease 
three  years  or  more  subsequent  to  operation  as  '  per- 
manent or  definite  cures.'  Semon  considers  a  case 
to  be  cured  that  is  free  from  any  recurrence  one  year 
after  operation,  and  states  that  it  has  been  his 
experience  that  recurrence  takes  place  within  a  year 
of  operation  or  not  at  all.  His  published  cases,  with 
their  results,  seem  to  bear  out  his  views. 

The  results  obtained  by  Butlin  and  Semon  are 
due  to  early  diagnosis  and  limitation  of  the  opera- 
tion most  rigidly  to  suitable  cases,  selected  by 
virtue  of  their  being  of  intrinsic  origin  and  limited 
in  extent. 

It  is  of  the  greatest  importance  to  operate  early  in 
these  cases,  and  thus  it  has  fallen  to  their  lot  to  have 
to  open  the  larynx  in  more  than  one  case  in  which 
there  was  a  doubt  as  to  the  nature  of  the  disease, 
and  the  diagnosis  could  not  be  cleared  up  by  the 
removal  of  a  fragment  through  the  mouth  for  micro- 
scopical examination.  When  the  disease  has  been 
found  to  be  of  an  innocent  nature  the  larynx  has 
been  closed  at  once,  and  no  evil  has  resulted.  On 
the  other  hand,  they  have  perhaps  erred  somewhat  in 
declining  to  operate  in  advanced  cases  of  carcinoma 
of  the  larynx,  and  have  very  infrequently  operated 
for  carcinoma  of  extrinsic  origin. 

Of  the  table  of  no  partial  laryngectomies  put 
together  by  Sendziak,   he   finds   lo   cases  which  he 


78    Malignant  Disease  of  the  Larynx 

claims  as  successes,  but  the  total  may  be  reduced  by 
deducting  some  14  or  15  cases  in  which  the  observa- 
tion of  the  case  lasted  less  than  a  year,  or  the  patient 
died  within  three  years  of  some  other  cause  than 
carcinoma  of  the  larynx  and  glands.  The  proportion 
of  successes  is,  therefore,  even  after  this  deduction, 
very  small,  about  the  same  as  was  obtained  by  the 
operation  of  thyrotomy.  It  is  here  of  great  impor- 
tance to  examine  the  class  of  cases  in  which  success 
was  obtained.  Seven  of  the  cases  were  certainly  of 
intrinsic  origin  and  only  one  of  them  certainly  ex- 
trmsic,  w^hile  in  the  two  remaining  cases  the  disease 
was  probably,  but  not  certainly,  intrinsic. 

By  the  exclusion  of  the  same  kind  of  cases  as  have 
been  excluded  in  considering  the  table  of  partial 
laryngectomies,  the  188  total  laryngectomies  of  Send- 
ziak  may  be  reduced  to  about  170,  and  there  are 
eleven  successes  to  be  claimed.  Among  the  excluded 
cases  it  is  wonderful  how  many  are  to  be  excluded  on 
account  of  death  from  pneumonia  or  bronchitis 
within  three  or  four  months  of  the  operation.  The 
proportion  of  cured  cases  is  lamentably  small,  while 
the  mortality  of  the  operation  is  extremely  large.  It 
is  very  difficult  in  most  of  the  successful  cases  to 
come  to  any  conclusion  as  to  the  extent  or  origin  of 
the  disease,  but  it  appears  generally  to  have  been 
very  extensive,  and  is  more  than  once  spoken  of  as 
filling  the  cavity  of  the  larynx. 

On  the  other  hand,  the  description  of  the  disease 
in  many  of  the  188  cases  inclines  one  to  the  belief 
that  total  laryngectomy  was  a  much  larger  operation 
than  was  necessary,  and  that  the  conditions  of  the 


Carcinoma  of  the  Larynx 


79 


case  might  well  have  been  met  by  partial  laryngec- 
tomy or  even  by  an  extensive  th3Totomy. 

As  might  be  expected,  the  ultimate  results  of  the 
cases  during  and  since  1888  are  somewhat  better 
than  those  of  the  cases  before  that  date.  It  has 
already  been  shown  that  the  death-rate  due  to  the 
operation  is  less,  and  of  the  56  patients  alive  and 
free  from  disease,  4  were  alive  and  free  from 
recurrence  more  than  three  years  after  the  opera- 
tion. 

That  the  results,  both  as  regards  recurrence,  cure, 
and  mortality  following  total  laryngectomy,  have 
been  steadily  improving  of  late  may  be  proved  by  the 
following  tables  of  comparison  : 


Sendziak's  Tables 

Schmiegelow's  Tables, 

(188  Cases). 

T890-1897  (50  Cases). 

Per  Cent. 

Per  Cent. 

Mortality 

447 

22 

Recurrence    -         -         - 

3-"45 

20 

Relative  cure  (less  than 

three  years) 

6-9 

48 

Definite  cure   (three   or 

more  years) 

5-85 

10 

The  results,  however,  obtained  by  Professor  Gluck, 
of  Berlin,  and  described  by  him  at  the  British 
Medical  Association's  meeting  at  Swansea,  July, 
1903,  are  most  surprisingly  brilliant,  and  hold  out 
the  greatest  hope  for  the  future.  He  stated  he  had 
performed  35  hemilaryngectomies  with  only  3  deaths, 
one  twenty- four  hours  after  operation  from  sudden 
heart  failure,  one  from  phlegmon  of  the  right  gluteal 
muscle,  and  one  from  pneumonia  on  the  fifth  day. 


8o    Malignant  Disease  of  the  Larynx 

He  also  had  performed  22  total  extirpations  of  the 
larynx  with  one  death,  this  being  in  an  old  man  of 
seventy,  who  succumbed  to  iodoform  poisoning  the 
eleventh  day  after  operation. 

He  also  performed  27  transverse  extirpations  of 
the  larynx,  pharynx,  and  glands,  with  again  only  i 
death.  He  furthermore  pointed  out  that  in  a  former 
series  of  9  cases  he  had  had  4  deaths  ;  and  going 
back  to  1888  and  the  first  cases,  there  had  been  only 
2  recoveries  out  of  10  operations. 

Professor  Gluck  said  he  could  have  brought 
forward  38  of  his  patients,  some  of  whom  had 
survived  operation  11,  8,  6J^,  5^,  4^,  and3i  years,  and 
were  in  full  health. 

Are  Patients  who  are  not  cured  relieved  by  the 
Operation  ? — Patients  on  whom  the  operation  of 
thyrotomy  or  partial  extirpation  of  the  larynx  has 
been  performed  are  generally  quite  comfortable  in  all 
respects.  They  are  not  obliged  to  wear  a  tube,  can 
swallow  well,  and  can  speak  sometimes  exceedingly 
w^ell,  and  at  all  times  in  a  gruff  whisper.  So  long, 
then,  as  there  is  no  recurrence  of  the  disease,  they 
are  absolutely  relieved  by  the  operation,  but  the 
voice,  of  course,  is  not  as  a  rule  improved  by  the 
operation,  although  it  maybe  quite  as  good  after  it  as 
it  was  for  some  time  previously. 

On  the  other  hand,  patients  who  have  undergone 
total  extirpation  of  the  larynx,  especially  when  the 
operation  has  been  extended  into  the  neighbouring 
soft  parts,  are  often  in  quite  a  miserable  condition. 
In  some  there  is  great  difficulty  in  swallowing.  All 
of  them  need  to  wear  a  tracheotomy  tube  unless  the 


Carcinoma  of  the  Larynx  8i 

trachea  is  fastened  to  the  opening  in  the  skin  ;  and 
the  artificial  larynx  is  much  more  troublesome  to 
wear  and  manage  than  is  usually  thought.  Further- 
more, there  is  no  doubt  that  these  patients  are  much 
more  liable  than  other  persons  to  pneumonia  and 
other  affections  of  the  lungs. 


Conclusions. 

Endolaryngeal  operations  are  only  indicated  in 
very  exceptional  circumstances.  The  disease  must 
be  very  limited  in  extent,  and  quite  superficial,  and 
even  then  endolaryngeal  removal  should  only  be 
adopted  in  those  cases  in  which  there  are  very 
urgent  reasons  against  opening  the  larynx,  or  in 
which  the  patient  refuses  a  major  operation. 

Thyrotomy  is  the  operation  for  all  cases  of  intrinsic 
carcinomas  in  which  the  disease  is  limited  to  the 
interior  of  the  larynx.  It  is  but  seldom  necessary  in 
such  cases  to  remove  any  of  the  framework  of  the 
larynx  except  when  the  disease  is  situated  at  the 
posterior  part  of  the  larynx. 

It  is  quite  sufficient  to  scrape  or  cut  away  the 
superficial  part  of  the  cartilage  beneath  the  base  of 
the  disease. 

Thyrotomy,  according  to  the  experience  of  English 
laryngologists,  is  a  safer  and  more  satisfactory  opera- 
tion than  the  various  modifications  of  pharyngotom}' 
for  the  removal  of  cancer  of  the  epiglottis  and  ary- 
epiglottic  folds,  etc. 

It  permits  of  a  more  thorough  exposure  of  the 
disease   and  of  greater  certainty  in  dealing  with  it, 

6 


82     Malignant  Disease  of  the  Larynx 

and  it,  moreover,  seems  to  be  less  dangerous  to 
life. 

Partial  excision  of  the  larynx,  either  of  one-half  or 
an  atypical  operation  adapted  to  the  extent  and 
character  of  the  disease,  is  suitable  to  cases  in  which 
the  disease,  although  of  intrinsic  origin,  is  of  greater 
extent  than  could  be  dealt  with  satisfactorily  by 
thyrotomy  and  removal  of  the  soft  parts. 

It  is  also  indicated  in  those  cases  in  which  rapid 
recurrence  has  followed  a  carefully  executed  thyro- 
tomy, and  in  cases  of  extrinsic  origin  limited  to  one- 
half  of  the  larynx. 

Total  extirpation  of  the  larynx  has  been  but 
seldom  performed  in  this  country,  and  has  been 
losing  favour  in  other  countries.  If  the  extent  of 
the  disease  be  so  great  that  partial  laryngectomy  will 
not  suffice,  the  prospect  of  success  from  an  operation 
has  been  hitherto  deemed  bad.  The  patient  is  much 
more  liable  after  it  to  pulmonary  affections,  particu- 
larly to  fatal  pneumonia,  and  the  mutilation  caused 
by  the  operation  is  often  so  considerable  that  the 
patient's  lot  is  a  very  sad  one.  At  the  same  time,  the 
results  obtained  by  Gluck,  and  already  referred  to, 
point  to  the  fact  that  total  laryngectomy  can  be  per- 
formed with  excellent  immediate  and  remote  results, 
and  should  go  a  long  way  towards  popularizing  an 
operation  hitherto  exceedingly  unpopular,  at  all 
events  in  this  country. 

The  operations  that  are  suitable  for  the  removal 
of  carcinoma  are  equally  suitable  for  the  removal  of 
sarcoma. 

Glandular    infection    occurs    late    in    cancers    of 


Carcinoma  of  the  Larynx  S; 


o 


intrinsic  origin,  especially  when  attacking  the  an- 
terior two-thirds  of  the  true  vocal  cords  or  the  false 
vocal  cords ;  it  occurs  equally  early  in  cancers  of 
extrinsic  origin.  It  is  probably  sound  surgery  to 
remove  the  glands  liable  to  infection,  whether  en- 
larged or  not,  in  all  cases  of  laryngeal  cancer 
excepting  those  attacking  the  anterior  two-thirds  of 
the  true  vocal  cords  or  the  false  vocal  cords,  in 
which  situations  experience  has  proved  that  glandular 
infection  but  rarely  occurs,  and  then  only  at  a  late 
stage  of  the  disease. 

The  most  promising  cases  of  carcinoma  for  opera- 
tion are  those  in  which  the  disease  is  situated  on  the 
anterior  two-thirds  of  the  true  vocal  cords  or  on  the 
false  vocal  cords,  is  small  in  extent  and  not  deeply 
fixed.  And  the  best  patients  are  those  who  other- 
wise are  in  good  health,  and  particularly  those  who 
are  not  liable  to  bronchitis.  Sarcomas  of  small  size 
and  of  intrinsic  origin  are  probably  equally  promising 
for  operation. 

Carcinomas  of  extrinsic  origin  are  always  much 
less  favourable  for  operation.  The  actual  removal 
of  the  disease  is  more  dangerous  to  life,  while  the 
greater  local  malignancy  of  the  disease  and  the  earh' 
tendency  to  infection  of  the  lymphatic  glands  render 
the  prospect  of  cure  poor. 

Palliative  Measures. 

It  appears,  from  a  consideration  of  the  cases  which 
have  been  treated  by  palliative  measures  only,  that 
the  life  of  a  patient  suffering  from  carcinoma  of  the 

6—2 


84    Malignant  Disease  of  the  Larynx 

larynx  may  last  as  long  as  two,  three,  and  even, 
though  rarely,  more  years  ;  and  life  may  often  be 
prolonged  and  rendered  far  more  comfortable  and 
the  end  more  easy  by  the  timely  performance  of 
tracheotomy.  Tracheotomy  is  therefore  indicated 
in  those  cases  of  laryngeal  cancer  which  are  con- 
sidered inoperable  and  in  which  there  is  increasing 
dyspnoea. 

Fauvel  gives  some  statistics  from  his  own  practice 
showing  the  utility  of  this  operation  as  a  palliative 
measure.  His  statistics  show  that  in  7  patients  on 
whom  tracheotomy  was  performed  for  carcinoma  of 
the  larynx  the  average  duration  of  life  was  four  years, 
whereas  in  6  patients  suffering  from  a  similar  con- 
dition, and  in  whom  no  operation  was  performed, 
the  average  duration  of  life  was  twenty-one  months. 

Dr.  Solis  Cohen,  in  a  paper*  on  excision  of  the 
larynx,  speaks  thus  of  tracheotomy  in  carcinoma  : 
'  Of  a  num.ber  of  cases  of  carcinoma  of  the  larynx 
under  my  own  care  who  agreed  to  submit  to  resection 
of  the  larynx  should  I  so  determine,  and  in  whom 
I  performed  tracheotomy  in  preference,  i  lived 
six  months,  2  lived  seven  months,  i  lived  thirteen 
months,  and  i  eighteen  months  respectively  after  the 
tracheotomy.  Had  laryngectomy  been  practised  in 
these  five  cases  with  equal  tenure  of  existence,  the 
result  would  have  been  accredited  to  the  radical 
procedure.'  If  tracheotomy  be  performed  the  low 
operation  should  be  chosen. 

Constitutional    treatment   holds   out    no   hope   of 

*  '  Does   Excision  of  the    Larynx  tend    to   Prolongation  of 
Life?'  p.  18.     Philadelphia,  1883. 


Carcinoma  of  the  Larynx  85 

cure.  Serum-therapy  has  been  given  an  extensive 
trial,  but  unfortunately  there  is  nothing  so  far  to  be 
said  in  favour  of  it  as  a  curative  agent.  The  same 
applies  to  the  employment  of  the  X  rays,  radium, 
etc.  In  inoperable  cases  pain,  if  present,  must  be 
relieved  by  the  insufflation  of  morphine,  J  to  h  grain, 
or  the  local  application  of  a  solution  of  cocaine  (10  to 
20  per  cent.).  Insufflations  of  orthoform  are  also 
much  in  vogue  at  present. 

When  there  is  much  ulceration  and  foetor,  inhala- 
tions of  creosote  or  benzoin  are  useful  and  soothing, 
or  a  powder  of  iodoform  gr.  i.,  ac.  borici  gr.  i., 
morph.  hydrochlor.  gr.  -J,  cocaine  gr.  J,  may  be  used 
for  insufflation.  It  is  necessary  to  warn  the  patient 
against  the  use  of  tobacco  and  strong  spirits. 

Should  there  be  pain  in  swallowing,  it  may  become 
necessary  to  adopt  rectal  feeding.  The  passage  of 
oesophageal  tubes  is  contra-indicated  in  these  cases, 
but,  if  employed,  Symonds'  tube  is  the  most  useful. 


86    Malignant  Disease  of  the  Larynx 


SARCOMA  OF  THE  LARYNX. 

Sarcoma  as  affecting  the  larynx  is  of  infinitely  less 
frequency  than  carcinoma.  In  olden  days  its  differ- 
entiation from  cancer  of  the  larynx  did  not  exist,  and 
it  has  been  only  during  the  last  thirty  years  that 
sufficient  attention  has  been  given  to  the  differential 
diagnosis  and  the  two  diseases  clearly  recognised. 
According  to  Sendziak,  the  first  case  of  primary 
sarcoma  of  the  larynx  to  be  met  with  in  medical 
literature  was  published  by  Broadbent  in  1861. 

Since  then  many  observers  have  worked  at  and 
written  on  the  subject.  Bergeat,  of  Munich,  has 
collected  from  various  sources  114  cases  of  sarcoma 
affecting  the  larynx  and  trachea,  and  various  authors 
have  referred  to  the  subject  in  their  works  on 
diseases  of  the  larynx  (Mackenzie,  Von  Ziemssen, 
Schrotter,  Massei,  Gottstein,  etc.). 

In  Butlin's  monograph  on  '  Malignant  Disease  of 
the  Larynx  '  (1883),  the  number  of  cases  of  sarcoma 
affecting  the  larynx  collected  from  various  sources 
amounted  to  23,  and  in  Sendziak's  recent  work  on 
'  Malignant  Disease  of  the  Larynx '  statistics  are 
given  of  50  cases  of  sarcoma. 


Sarcoma  of  the  Larynx  Sy 


ETIOLOGY. 

The  etiology  of  sarcoma  of  the  larynx  is  practically 
unknown.  Occupation  does  not  seem  to  have  exer- 
cised any  marked  influence  in  the  production  of  the 
tumours,  but  the  great  preponderance  of  males  among 
the  patients — in  Sendziak's  tables  of  50  cases,  31 
males,  13  females ;  in  Bergeat's,  48  males,  18  females 
— may  suggest  that  strong  and  over  use  of  the  voice, 
with  perhaps  tobacco-smoke  and  other  irritants,  play 
a  part  in  the  etiology  of  sarcoma.  Bergeat  refers  to 
the  fact  that  in  many  of  the  cases  collected  by  him 
the  patients  were  more  or  less  connected  in  their 
work  with  horses,  and  both  he  and  Von  Esmarch 
believe  syphilis  to  be  a  strong  predisposing  agent. 

In  some  instances  sarcomatous  tumours  of  the 
larynx  have  been  attributed  to  severe  colds. 

Frequency. — As  already  stated,  sarcoma  is  infinitely 
more  uncommon  than  carcinoma  of  the  larynx,  the 
proportion  of  cases  being  variously  put  at  i  to  11  or  12, 
I  to  17-25  (Schmidt). 

Mackenzie,  in  his  practice,  out  of  53  cases  of 
malignant  tumours,  only  met  with  it  in  5,  and  Semon 
3  times  out  of  103  cases  of  malignant  disease  of  the 
larynx  ;  Massei,  out  of  200  similar  cases,  6  times. 

Again,  in  relation  to  sarcoma  occurring  in  other 
parts  of  the  body,  it  is  found  that  the  larynx  is  a 
rare  organ  to  be  attacked.  Gurlt,  out  of  848  cases  of 
sarcoma,  noted  the  presence  of  one  solitary  case  in 
the  lar^^nx. 

Age. — Age  does  not  play  so  important  a  part  as  in 


Years. 

7 

13 

i8 

19 

Between 

I  21  and  30 

5? 

31  and  40 

5) 

41  and  50 

55 

5  r  and  60 

5) 

61  and  70 

74 

Not  noted - 

SS    Malignant  Disease  of  the  Larynx 

carcinoma.  Sarcoma  is  frequently  met  with  at  an 
earlier  age  than  carcinoma,  as  the  following  analysis 
of  Sendziak's  50  cases  shows  : 

Cases. 

-  I 

I 
I 
I 

-  6 

-  6 

-  10 

-  13 


43 
-       7 

50 

The  youngest  of  the  patients  was,  accordingly, 
7  years  of  age,  the  oldest  74  (Semon  has  met  with  a 
case  in  a  man  of  81),  but  in  the  first  case  the  disease 
was  believed  to  be  congenital. 

Bergeat's  statistics  give : 

Years.  Cases. 

Between  20  and  30  -  -  -       6 

„         30  and  40  -  -  -     1 1 

„         40  and  50  -  -  -     13 

From  40  to  60  may  be  said  to  be  the  commonest 
age  for  sarcoma  of  the  larynx.  In  women  it  has 
been  noted  most  frequently  from  30  to  50  years  of 
age,  and  in  men  from  50  to  60. 

In  those  over  60  years  of  age  the  male  sex  pre- 
ponderates (Lange  74,  Semon  81). 


Sarcoma  of  the  Larynx  89 

Situation. — As  in  carcinoma,  sarcoma  of  the  larynx 
can  best  be  classified  as  (i)  intrinsic,  (2)  extrinsic  in 
origin. 

In  23  cases  collected  by  Butlin  in  1883,  17  were 
intrinsic,  3  extrinsic,  and  3  of  uncertain  origin. 

In  Sendziak's  50  cases,  26  were  of  intrinsic  and  15 
of  extrinsic  origin,  and  9  not  noted. 

In  some  of  the  cases  the  whole  of  the  interior  of 
the  larynx  was  occupied  by  the  disease,  but  where 
the  seat  of  origin  could  be  distinguished,  it  was  for 
the  large  majority  of  the  intrinsic  sarcomas  the  true 
vocal  cords  or  the  ventricular  bands,  of  the  extrinsic 
sarcomas  the  epiglottis. 

Taking  the  two  classes  together,  the  order  of 
frequency  may  be  said  to  be,  first,  the  true  vocal 
cord,  next  the  epiglottis,  then  the  false  vocal  cord, 
and  more  rarely  the  posterior  part  of  the  larynx  and 
ventricle  of  Morgagni. 

As  in  carcinoma,  it  is  very  rare  to  find  the  sinus 
pyriformis   the  original    seat    of  growth.       It   is   or 
importance  to    remember  that  the  disease   may  be 
infraglottic ;    Sendziak  reports  6  such  cases  out  of 
his  series  of  50  sarcomas  of  the  larynx. 

Apparently,  the  left  half  of  the  larynx  is  more 
frequently  attacked  than  the  right,  and  there  is  no 
reason  known  why  this  should  be  so.  Sarcoma  of 
the  larynx  may  be  primary  or  secondary  in  origin. 
In  97  cases  noted  by  Bergeat  85  were  primary  and 
12  secondary,  the  latter  mostly  arising  from  con- 
tinuity of  tissue,  and  but  very  rarely  from  metas- 
tasis. 

In  connection  with  the  subject  of  metastasis,  it  is 


90    Malignant  Disease  of  the  Larynx 

to  be  noted  that  out  of  the  50  cases  already  referred 
to  (Sendziak's)  of  laryngeal  sarcoma  there  was  but 
I  case  (Table  VII.,  Case  6)  in  which  post-mortem  ex- 
amination revealed  a  secondary  growth  (in  the  lung). 

Rollier,  however,  has  reported  a  case  of  sarcoma 
of  the  larynx  with  secondary  growths  in  the  lungs, 
liver,  and  brain,  and  Koschier  one  in  which  lympho- 
sarcoma of  the  breast,  sternum,  mediastinum,  pleurae, 
glands,  pharynx,  and  larynx  was  found. 

Out  of  the  23  cases  collected  by  Butlin  the  number 
of  complete  autopsies  was  only  2  ;  in  neither  of  them 
were  secondary  tumours  found,  nor  were  there  any 
signs  which  denoted  the  formation  of  secondary 
tumours  in  any  of  the  patients  before  death.  He 
therefore  stated :  '  A  more  extended  series  of  obser- 
vations may  show  that  secondary  growths  are  not 
uncommon,  but  the  evidence  at  present  before  us 
seems  to  prove  that  sarcoma  of  the  larynx  neither 
affects  the  lymphatic  glands  nor  produces  secondary 
growths,  and  that  its  malignant  properties  are  limited 
to  infiltration  of  adjoining  parts.'  These  views  were 
expressed  in  1883,  and  not  only  does  further  ex- 
perience prove  the  rarity  of  secondary  growths,  but 
also  that  involvement  of  the  glands  in  the  neighbour- 
hood is  the  exception  and  not  the  rule. 

Out  of  Sendziak's  50  cases  only  3  are  mentioned 
in  which  the  glands  were  affected — namely,  Table  V., 
Case  4.  A  man  aged  fifty-one  with  a  round-celled 
sarcoma  under  the  left  vocal  process.  Laryngo-fissure 
and  excision  of  the  affected  glands  was  performed 
with  good  results  (Bessel  and  Hagen). 

Table  VI.,  Case  8. — A  male  aged  fifty-seven  with 


Sarcoma  of  the  Larynx  91 

a  round-celled  sarcoma  affecting  the  right  processus 
vocalis.  The  right  half  of  the  larynx  and  the  affected 
glands  were  removed.  Death  ensued  three  days  later 
from  coma  (Gluck). 

Table  VII.,  Case  2. — A  male  aged  forty-six  with 
ulcerating  lympho-sarcoma  of  the  base  of  the  epi- 
glottis. Total  laryngectomy  and  excision  of  the 
affected  glands  was  performed.  Death  ensued  fifteen 
months  later  from  recurrence  (Czerny). 

The  absence  of  glandular  affection  in  sarcoma  of 
the  larynx  has  been  clearly  recognised  by  most  of 
those  who  have  written  on  the  subject,  and  is  a 
matter  of  great  importance,  both  from  a  pathological 
and  clinical  point  of  view. 

Reference  has  already  been  made  to  the  distribu- 
tion of  the  lymphatic  vessels  of  the  larynx  in  treating 
of  carcinoma  of  that  organ,  and  it  can  scarcely  be 
maintained  that  the  absence  of  lymphatic  vessels  is 
the  reason  why  sarcomas  do  not  affect  the  lymphatic 
glands.  The  extrinsic  parts  of  the  larynx  at  all 
events  are  very  amply  provided  with  lymphatics, 
and  it  has  been  already  pointed  out  that  carcinoma 
of  these  parts  affect  the  lymphatic  glands  at  an  early 
period  ;  yet  sarcoma  affecting  these  same  parts  does 
not  lead  to  glandular  involvement  or  secondary 
growths.  They,  however,  give  evidence  of  their 
malignant  properties  in  the  manner  in  which  they 
infiltrate  the  tissues,  and  in  the  obstinacy  with  which 
some  of  them  recur  after  what  appears  to  be  complete 
removal. 

Taking  now  the  microscopical  characters  of  the 
various  sarcomata  of  the  larynx  met  with,  it  is  found 


92     Malignant  Disease  of  the  Larynx 

that  in  nearly  half  the  cases  the  tumour  was  spindle- 
celled,  or  composed  of  cells  closely  resembling  the 
typical  spindle  cell.  Included  in  this  variety  are  the 
cases  described  as  fibro-sarcomata.  Next  in  frequency 
come  the  round-celled  tumours,  and  finally  alveolar 
sarcoma. 

The  foUow^ing  varieties  have  also  been  noted  by 
various  authors,  but  are  all  of  exceptional  rarity  ; 
sarcoma  carcinomatodes,  myeloid,  chondro-,  angio-, 
adeno-,  lympho-sarcoma,  melanotic  and  papillary 
sarcoma.  In  many  cases  recorded  the  tumours  are 
merely  said  to  be  *  sarcomas.' 

Szmurlo  has  described  a  very  interesting  case  of 
mixed  cancer  and  sarcoma  of  the  larynx. 


CLINICAL  VARIETIES  AND  SYMPTOMS. 

Sarcoma  of  the  larynx  presents  itself  clinically  in 
very  varied  forms,  according  to  the  time  the  disease 
has  been  in  existence.  It  always  forms  a  definite 
tumour,  generally  diffuse  in  character,  and  with  a 
broad  base  arising  from  the  true  or  false  vocal  cord, 
epiglottis,  or  aryepiglottic  fold.  It  is  uncommon  to 
find  it  presenting  itself  as  a  circumscribed  tumour  of 
a  polypoidal  type,  and  in  those  cases  partaking  of 
this  character  the  origin  has  been  almost  invariably 
the  true  vocal  cord. 

The  tumour  seldom  grows  to  a  large  size,  the 
largest  examples  only  attaining  the  size  of  a  walnut 
or  a  little  larger. 

The   mucous  membrane  covering  the  tumour   is 


Sarcoma  of  the  Larynx  93 

generally  discoloured,  the  character  of  the  discolora- 
tion varying  considerably,  some  of  the  tumours  being 
much  paler  than  the  normal  mucous  membrane, 
others  much  darker,  either  deep  red  or  livid,  and 
traversed  by  large  full  vessels. 

In  shape  the  neoplasm  is  generally  round,  with  a 
variable  surface.  The  latter  may  be  smooth,  uneven, 
or  wart-like.  Mackenzie  noted  a  wart-like  appear- 
ance in  4  out  of  his  5  cases. 

Sooner  or  later  infiltration  invariably  takes  place. 
In  the  worst  cases  the  tumour,  being  of  extrinsic 
origin,  has  grown  into  the  base  of  the  tongue  or 
wall  of  the  pharynx  ;  or,  being  of  intrinsic  origin, 
has  extended  through  the  membranes  or  the  thyroid 
cartilage  into  the  hyoid  muscles. 

One  of  the  most  characteristic  features  of  laryngeal 
sarcoma  is  the  absence  of  ulceration.  When  ulcers 
are  seen  they  are  generally  small  and  superficial.  As 
in  carcinoma,  perichondritis,  with  all  its  after-effects, 
may  occur. 

Most  of  the  tumours  feel  firm  or  hard  when 
examined  with  the  laryngeal  probe,  although  Schmidt 
is  of  a  different  opinion.  Bergeat  noted  15  cases 
as  hard  and  13  as  soft.  In  a  few  cases  the  tumour 
has  been  of  mixed  consistency — hard  at  the  base 
and  soft  at  the  apex.  As  a  rule,  the  growth  is 
solitary,  although  in  a  few  rare  cases  two  or  more 
growths  have  been  present  either  close  together  or 
separated  by  a  narrow  interval,  while  in  one  instance 
two  growths  were  attached  to  the  two  vocal  cords, 
and  were  separated  by  a  narrow  chink  of  glottis 
(Schnitzler-  Krajewski) . 


94    Malignant  Disease  of  the  Larynx 

The  course  of  the  disease  is  certainly  more  rapid 
than  in  carcinoma,  especially  in  cases  of  so-called 
alveolar  sarcoma.  Burow  has  recorded  an  example 
in  which  the  tumour,  which  grew  from  the  posterior 
aspect  of  the  epiglottis,  was  as  large  as  a  small 
walnut  when  an  attempt  was  made  to  remove  it  six 
weeks  after  the  symptoms  were  first  noticed.  It  was 
a  spindle-celled  sarcoma. 

Symptoms. 

The  symptoms  of  sarcoma  affecting  the  larynx  are 
very  similar  to  those  of  simple  laryngeal  tumours. 
One  of  the  earliest  symptoms  is  hoarseness  or  some 
slight  affection  of  the  voice,  although  this  is  much 
less  frequent  and  marked  than  in  carcinoma. 

Pain,  especially  in  the  early  stages,  is  absent,  or 
only  slight,  though  it  may  become  more  marked 
later  on.  At  all  events,  it  is  invariably  much  less 
intense  than  in  carcinoma.  There  may  be  a  feeling 
as  of  a  foreign  body  in  the  throat,  and  the  patient 
may  suffer  from  impeded  respiration,  and,  as  the 
glottis  becomes  narrowed,  stenosis  may  become  well 
marked. 

Dysphagia,  especially  in  sarcoma  attacking  the 
epiglottis,  is  often  present,  and  may  sometimes  be 
very  severe. 

Secretion  is  usually  insignificant ;  if  ulceration  be 
present  it  may  be  blood-stained. 

As  already  stated,  the  neighbouring  glands  are  in 
most  instances  not  affected,  although  they  are  liable 
to  become  involved  in  the  later  periods  of  the  disease. 


Sarcoma  of  the  Larynx  95 

Even  in  the  later  stages,  however,  the  glands  usually 
escape  infection. 

Limited  movement  of  the  cords  may  be  present 
or  absent,  although,  according  to  some  laryngolo- 
gists,  this  symptom  has  not  the  same  significance  as 
in  carcinoma. 

Diagnosis. 

Before  a  course  of  treatment  which  may  be  deemed 
suitable  to  any  given  case  can  be  pursued,  a  correct 
diagnosis  of  the  nature  of  the  tumour  must  be  made. 

In  some  instances  it  may  be  easy  to  decide  that  a 
certain  tumour  is  sarcomatous,  but  this  is  not  at  all 
the  rule.  It  is  usually  very  difficult  to  distinguish 
from  the  objective  symptoms  or  from  the  external 
characters  of  the  tumour  between  sarcoma  and 
carcinoma  on  the  one  hand,  between  sarcoma  and 
innocent  tumours  on  the  other  hand.  It  is  also 
difficult  to  diagnose  in  certain  cases  between  sarcoma 
and  gummatous  deposits  or  syphilitic  perichondritis. 

The  external  characters  of  the  tumour,  although 
they  may  lead  to  the  suspicion  that  the  disease  is 
malignant  and  yet  not  carcinoma,  can  seldom  be 
implicitly  relied  on.  The  absence  of  ulceration  has 
already  been  alluded  to,  but  ulceration  may  be 
absent  in  carcinoma,  and  is  generally  absent  in  non- 
malignant  tumours. 

Fortunately,  however,  the  diagnosis,  which  might 
seem  from  what  has  just  been  said  to  be  so  difficult, 
may  easily  be  made  in  almost  every  case  by  compara- 
tively simple  means.  A  portion  of  the  tumour  may 
be  removed  with  the  cutting  laryngeal  forceps,  and 


96    Malignant  Disease  of  the  Larynx 

be  subjected  to  microscopical  examination.  Tumours 
of  the  epiglottis  and  extrinsic  portions  of  the  larynx 
may  be  treated  in  this  way  with  scarcely  any  difficulty ; 
tumours  of  the  ventricular  bands  and  vocal  cords 
wdth  greater  difficulty,  of  course,  but  with  a  difficulty 
which  depends  largely  on  the  size  and  exact  situa- 
tion of  the  tumour.  It  must  be  understood  that  the 
fragment  thus  removed  be  subjected  to  a  searching 
microscopical  examination,  and  that  several  sections 
of  the  fragment  removed  be  made.  It  is  important 
to  examine  all  parts  of  the  excised  fragment,  especi- 
ally its  base.  The  removal  endolaryngeally  of  even 
a  large  fragment  is  productive  of  scarcely  any  pain, 
and  so  far  from  being  dangerous,  has  often  afforded 
marked  temporary  relief. 

Prognosis. 

Sarcoma  of  the  larynx,  compared  with  carcinoma, 
offers  a  much  more  favourable  prognosis,  both  with 
regard  to  life  and  tendency  to  recurrence.  In  com- 
parison with  innocent  tumours  the  prognosis  is  a 
great  deal  worse. 

The  tendency  of  the  disease  is  to  cause  death  from 
suffocation  or  exhaustion,  and  this  may  take  place 
within  a  year  or  eighteen  months  of  the  first  appear- 
ance of  the  disease.  Usually,  however,  the  course  of 
the  disease  is  much  slower,  and  the  patient  may  live 
for  two,  three,  or  more  years. 


Sarcoma  of  the  Larynx  97 

Treatment. 

It  is  hardly  necessary  to  mention  that  the  only 
rational  treatment  for  laryngeal  sarcoma  is  operative. 
Palliative  treatment  may  demand  tracheotomy,  and 
in  some  cases  Coley's  fluid  (toxin  of  Streptococcus 
ery  sip  el  at  OS  us  and  Bacillus  prodigiosus)  has  been  in- 
jected, but  with  no  good  results. 

Such  measures  as  the  employment  of  the  galvano- 
cautery,  the  use  of  caustics,  etc.,  should  be  strongly 
condemned,  for  they  merely  stimulate  the  activity  of 
the  growth. 

The  operative  measures  that  have  been  employed 
for  the  removal  of  sarcoma  of  the  larynx  are  as 
follows  : 

1.  Endolaryngeal  Removal. 

2.  Suprathyroid  Laryngotomy. 

3.  Infrathyroid  Laryngotomy. 

4.  Thyrotomy. 

5.  Partial  Extirpation  of  the  Larynx. 

6.  Total  Extirpation  of  the  Larynx. 

(i)  Endolaryng-eal  Removal. — If  mere  removal 
with  endolaryngeal  forceps  ^er  vias  naturales  be  con- 
sidered, few,  if  any,  complete  recoveries  can  be 
claimed.  In  the  section  of  his  work  which  is  devoted 
to  sarcoma  Mackenzie  spoke  hopefully  of  the  endo- 
laryngeal method,  and  stated :  '  In  one  case  I  suc- 
ceeded in  permanently  removing  the  growth  per  vias 
naturales,  and  Navratil,  Gottstein,  Tiirck,  and  others 
have  effected  cures  in  this  way.'  This  was  in  the 
year  1881. 

7 


98    Malignant  Disease  of  the  Larynx 

Now,  on  examining  these  references  of  Mackenzie's, 
we  find  that  in  only  one  case,  that  of  Gottstein's, 
was  a  permanent  cure  effected.  The  patient  was  a 
boy  aged  seven,  suffering  from  a  fibro-sarcoma  of  the 
vocal  cord ;  the  tumour  was  removed  with  a  snare, 
and  thirteen  years  later  the  boy  was  still  well  and  his 
voice  good. 

In  Navratil's  case  the  diagnosis  was  not  confirmed 
microscopically,  and  the  later  history  of  the  case  is 
unknown. 

In  Tiirck's  case,  a  round-celled  sarcoma  of  the  left 
vocal  cord,  the  subsequent  history  is  also  unknown. 

Taking  Sendziak's  series  of  cases,  we  find  he  has 
collected  13  in  which  endolaryngeal  removal  was 
performed. 

Of  actual  cures — that  is  to  say,  longer  than  three 
years  without  recurrence — there  is  only  i  case, 
namely,  that  of  Gottstein's,  already  referred  to. 

Of  relative  cures — that  is  to  say,  no  return  up  to 
one  year  after — 2  cases. 

Of  recurrences  5  cases  (i.e.,  from  two  to  eight 
months).     Results  uncertain,  5  cases. 

What  has  already  been  said  as  to  the  limitation  of 
this  method  of  operation  with  regard  to  carcinoma 
of  the  larynx  holds  equally  good  in  connection  with 
sarcoma.  Only  in  those  suffering  from  extreme  old 
age  or  grave  impairment  of  the  health  should  this 
method  be  attempted. 

(2)  Suprathyroid  Laryngotomy.  —  The  number 
of  cases  in  which  suprathyroid  laryngotomy  has 
been  performed  is  too  few  to  be  able  to  judge  the 
value  of  the  operation. 


Sarcoma  of  the  Larynx  99 

It  has  been  performed  for  the  removal  of  growths 
situated  at  the  upper  opening  of  the  larynx,  particu- 
larly in  connection  with  the  epiglottis. 

Burow,  for  instance,  has  described  the  case  of  a 
man  thirty  years  of  age  who  suffered  from  a  spindle- 
celled  sarcoma  of  the  epiglottis.  It  was  removed 
with  forceps  and  cautery,  a  little  later  with  the  steel 
loop,  and  again  a  few  days  later  with  a  sharp  spoon 
and  scissors,  after  a  free  incision  had  been  made  in 
the  sublingual  region.  Eighteen  months  after  the 
last  operation  the  patient  was  quite  well.  This  is 
the  more  remarkable  because  the  original  tumour  had 
grown  very  rapidly,  and  recurrence  had  taken  place 
almost  immediately. 

(3)  Infrathyroid  Laryngotomy. — What  has  already 
been  said  as  to  the  indications  and  value  of  this 
operation  as  applied  to  carcinoma  of  the  larynx 
equally  applies  to  sarcoma  of  the  larynx. 

(4)  Thyrotomy  or  Laryngo-fissure. — The  first 
case,  apparently,  in  which  thyrotomy  was  performed 
for  sarcoma  of  the  larynx  is  mentioned  by  Laroyenne. 
The  patient  was  a  woman  suffering  from  a  spindle- 
celled  sarcoma  of  the  right  vocal  cord,  which  had 
been  growing  for  about  twelve  months.  It  was 
removed  after  division  of  the  thyroid  cartilage. 
Eight  months  after  the  operation  she  was  free  from 
disease. 

Sendziak  has  collected  12  cases  of  sarcoma  in  which 
thyrotomy  was  performed.  Two  of  the  12  patients 
were  well  and  free  from  disease,  i  four  years 
after  the  operation,  and  the  other  nearly  five 
years     after    it    was    performed.      This,    therefore, 

7—2 


loo    Malignant  Disease  of  the  Larynx 

insures  2  thoroughly  successful  cases  out  of  the  total 
of  12. 

None  of  the  other  patients  can  be  claimed  to  have 
been  cured,  but  4  of  them  were  well  two  years,  or 
nearly  two  years,  after  the  operation,  and  2  other 
patients  were  well  a  year  after  the  operation.  There 
were  2  cases,  also,  in  whom  too  short  a  period  had 
elapsed  since  the  operation  to  judge  of  the  results, 
while  recurrence  of  the  disease  was  only  noted  in 
2  of  the  12  cases. 

In  no  case  was  there  a  fatal  issue  from  the  opera- 
tion itself,  and  the  phonatory  results  were  as  good  as 
the  general  results. 

(5)  Partial  Laryngectomy. — In  Sendziak's  tables 
there  is  a  series  of  10  cases  recorded  in  which  partial 
laryngectomy  was  performed  for  sarcoma. 

The  results  are  very  different  from  those  following 
thyrotomy. 

One  patient  was  free  from  recurrence  four  years 
after  the  removal  of  a  round-celled  sarcoma  of  the 
left  true  and  false  cords  (Bull,  of  America).  Three 
died  of  lung  mischief  (apparently  non-malignant)  at 
periods  of  three  months,  twelve  months,  and  eighteen 
months  after  the  operation,  and  without  any  sign  of 
recurrence  of  the  disease.  One  patient  suffered  from 
immediate  recurrence  of  the  disease,  and  Kiister 
successfully  removed  the  whole  of  the  larynx. 
Another  patient  died  of  recurrence  two  and  a  half 
years  after  operation.  Three  patients  died  as  a 
result  of  the  operation,  2  on  the  third  day  from  coma, 
and  I  from  pneumonia.  The  remaining  patient  was 
still  well  about  a  year  after  the  operation. 


Sarcoma  of  the  Larynx     ioi 

(6)    Total    Extirpation    of    the    Larynx.  —  An 

analysis  of  Sendziak's  ii  cases  furnishes  really 
better  results. 

There  were  3  cases  of  definite  cure,  i  patient 
being  quite  well  seven,  another  eight,  and  yet 
another  fifteen  years  after  the  operation.  Of  the 
remaining  8  cases,  however,  it  is  found  that  4 
died  of  recurrence  of  the  disease  five  months,  seven 
months,  one  year,  and  fifteen  months  respectively 
after  the  operation,  and  3  as  a  result  of  the 
operation,  w^hile  in  i  case  the  time  that  had 
elapsed  since  operation  was  too  short  to  be  able  to 
judge  of  the  result. 

The  results,  therefore,  of  the  ^^  operations 
included  under  thyrotomy,  partial  and  complete 
laryngectomy,  can  hardly,  from  any  point  of  view,  be 
called  good,  yet  they  are  not  wholly  bad,  because,  in 
addition  to  the  really  successful  cases,  there  are 
several  in  which  there  is  reason  to  hope  that  the 
result  proved  quite  successful. 

The  successful  laryngectomies  were  performed  for 
three  varieties  of  sarcoma,  one  round  and  spindle- 
celled,  the  second  lympho-sarcoma,  and  the  third 
'  sarcoma  carcinomatodes.' 

The  results  of  these  various  operations  for  sarcoma 
of  the  larynx,  when  compared  together,  work  out  as 
follows  : 

Per  Cent,  of 
Good  Results. 

1.  Thyrotomy  (best  measure)  -  -     58'3 

2.  Total  laryngectomy  .  .  .     ^6'^ 

3.  Partial  laryngectomy         -  -  -30 

4.  Suprathyroid  laryngotomy  -  -     ^S 

5.  Endolaryngeal  removal    -  -  -     23 


I02    Malignant  Disease  of  the  Larynx 

By  good  results  are  understood  the  cases  of  definite 
as  well  as  relative  cures. 

If  we  take  the  definite  cures  by  themselves  the 
results  work  out  as  follows  : 

Per  Cent. 

1.  Total  laryngectomy  -  -  -  27'3 

2.  Partial  laryngectomy  -  -  -  lo'o 

3.  Thyrotomy             _  .  .  .  g-^ 

4.  Endolaryngeal  removal  -  -  -  8'o 

The  relative  cures  give  : 

Per  Cent. 

1.  Thyrotomy  -  -  -  "     50 

2.  Partial  laryngectomy  -  -  -     20 

3.  Endolaryngeal  removal  -  -  -15 

4.  Total  laryngectomy  -  -  -       9 

Now,  taking  the  had  results  as  regards  {a)  recur- 
rence, {b)  fatal  results,  we  find  : 

{a)  Recurrence. 

Per  Cent. 

Endolaryngeal  ...  -  38-5 

Partial  laryngectomy  -  -  -  20 

Total  laryngectomy  -  -  -  -  18 

Thyrotomy     -----  i6'6 

(b)  Fatal  Results  {within  Two  Weeks  of  the  Operation). 

Per  Cent. 

Partial  laryngectomy  -  ■  -     80 

Total  laryngectomy  -  -  -  -     27 '3 

There  have  been  no  fatal  results  at  all  from 
thyrotomy  or  endolaryngeal  operation. 

Where  total  laryngectomy  is  indicated,  the  results 
apparently  are  better  than  in  similar  conditions  for 
carcinoma  of  the  larynx. 

The  treatment  of  sarcoma  of  the  larynx  is  thus  in 
most  instances  clear. 


Sarcoma  of  the  Larynx     103 

When  the  disease  is  of  intrinsic  origin,  limited  in 
extent,  especially  to  one  cord  or  ventricular  band, 
thyrotomy  should  undoubtedly  be  performed.  Simi- 
larly, thyrotomy  is  indicated  after  recurrence  follow- 
ing the  endolaryngeal  method  (this  latter  method 
should,  however,  only  exceptionally  be  advised),  and 
also  as  a  preliminary  diagnostic  step  to  laryngectomy. 
When,  after  thyrotomy,  the  disease  recurs  and  ex- 
hibits signs  of  more  extensive  infiltration,  or  when 
from  the  first  it  presents  a  much  more  formidable 
appearance — in  those  instances,  for  example,  when 
the  entire  larynx  seems  filled  by  a  sarcomatous 
tumour,  the  attachments  of  which  are  evidently 
deep-seated  and  widely  extended — the  question  of 
removal  of  the  larynx,  either  partial  or  complete, 
will  naturally  be  raised. 

If  the  patient  be  not  too  old  or  weak  for  so  severe 
an  operation,  and  if  it  be  certain  that  the  disease  can 
be  entirely  removed,  especially  if  it  be  limited  to  the 
interior  of  the  larynx,  and  that  at  the  same  time 
thyrotomy  will  not  meet  the  case,  then  extirpation, 
partial  or  complete,  of  the  affected  organ  is  indi- 
cated. 

The  question  very  naturally  arises  how  far  the 
removal  of  the  larynx  contributes  to  a  fatal  issue 
from  pulmonary  disease.  Out  of  Sendziak's  21  cases 
a  fatal  issue  from  lung  trouble  occurred  in  4  patients ; 
I,  three  months  after  operation,  from  pneumonia; 
2  from  pleuritis,  twelve  and  fifteen  months  respec- 
tively after  operation ;  and  i  from  tubercle,  eighteen 
months  subsequent  to  removal  of  the  larynx.  Of 
deaths  from  the  operation   itself  there  are  5  cases, 


I04    Malignant  Disease  of  the  Larynx 

and  of  these  3  were   from   pneumonia  and   2  from 
coma. 

There  can  therefore  scarcely  be  a  doubt  that 
removal  of  the  larynx,  either  partial  or  complete, 
must  increase  the  liability  to  pulmonary  affections, 
immediate  or  remote. 

This,  however,  should  not  contra-indicate  the  per- 
formance of  the  operation  whenever  it  is  clearly  indi- 
cated in  cases  of  sarcoma.  Improved  methods  of 
operation  have  of  recent  years  tended  to  lessen  these 
liabilities,  and  it  must  be  remembered  that  death 
from  an  acute  or  even  tolerably  chronic  pulmonary 
disease  is  in  most  instances  preferable  to  death  from 
obstruction  of  the  larynx  and  its  attendant  evils 
when  the  obstruction  is  due  to  a  sarcomatous 
tumour. 

Contra-indications  to  the  operation  (partial  or 
complete  laryngectomy)  are  general  bad  condition 
of  the  patient,  too  extensive  growth,  affection  of  the 
neighbouring  parts — i.e.,  pharynx,  etc. — and,  lastly, 
tubercle  of  the  lungs. 


INDEX 


CARCINOMA  OF  THE  LARYNX 


After-treatment    of    opera- 
tions, 6i 
Age,  6 

Anatomy,  pathological,  g 
Auto-infection,  6 

Benign  tumours,  45 

Cachexia,  38 

Cannula,  54 

Chronic  irritation,  4 

Chronic  laryngitis,  44 

Complete  excision  of  larynx,  61 

Contagion,  6 

Cures  due  to  operation,  75 

Diagnosis,  42 

differential,  44 

from  benign  tumours,  45 
from  chronic  laryngitis, 
from  lupus,  48  [44 

from  pachydermia,  46 
from  paralyses,  48 
from  syphilis,  47 
from  tubercle,  48 

Dysphagia,  37 

Dyspnoea,  37 

Endolaryngeal  operations,  50 

Etiology,  3 

Excision  of  glands,  82 

of  larynx,  61 
Expectoration,  37 
Extrinsic  carcinoma,  9,  16 

symptoms  of,  35 


Glands,  excision  of,  82 
immunity  of,  25 
implication  of,  22,  27 
prelaryngeal,  14,  26 
pre-tracheal,  15,  26 
pre-thyroidean,  15,  26 
recurrent  laryngeal,  15,  26 
sterno-mastoid,  15,  26 

Haemorrhage,  37 
Heredity,  3 

Histological  structure,  33 
History,  i 
Hoarseness,  34 

Impaired  mobility  of  vocal  cords, 

40,  44 
Indications  for  operation,  81 
Infrathyroid  laryngotomy,  52 
Intrinsic  carcinoma,  9,  17 
symptoms  of,  34 

Lupus,  48 

Lymphatic  channels,  13 
Lymphatic  radicles,  12 
Lymphatics  of  larynx,  10 

attenuation  of,  12,  21 

atrophy  of,  21,  26 

Mortality  from  partial  excision 
of  larynx,  73 
from  total  excision  of  larynx, 

74 
from  thyrotomy,  71 


105 


io6    Malignant  Disease  of  the  Larynx 


CEdema,  39 

Pachydermia,  46 

Pain,  36 

Palliative  treatment,  83 

Paralyses,  48 

Partial  excision  of  larynx,  68 

cures  from,  77 

indications  for,  81 

mortality  from,  73 

recurrence  after,  79 
Pathological  anatomy,  9 
Perichondritis,  38 
Prelaryngeal  glands,  14,  26 
Pre-thyroidean,  15,  26 
Pre-tracheal  glands,  15,  26 
Prognosis,  49 

Radical  treatment,  50 
Radium,  85 

Recurrence  after  operation,  79 
Recurrent  laryngeal  glands,  15, 
26 

Secretion,  35 
Serum  therapy,  85 


Sex,  8 
Signs,  38 

Simple  tumours,  5 
Sterno-mastoid  glands,  15,  26 
Subglottic  carcinoma,  18 
Subhyoid  pharyngotomy,  51 
Suprathyroid  laryngotomy,  51 
Symptoms,  34 
Syphilis,  5,  47 

Tampon  cannula,  54 

Thyrotomy,  operation  of,  53 
cures  from,  76 
indications  for,  81 
mortality  from,  6g,  71 
recurrence  after,  79 
shears  for,  55 

Tracheotomy,  84 

Tubercle,  5,  48 

Ulceration,  39 

Vocal  cords,  impaired  mobility 
of,  40,  44 

X  rays,  85 


SARCOMA  OF  THE  LARYNX 


Age,  87 

Clinical  varieties,  92 
Coley's  fluid,  97 
Consistency,  93 

Contra-indications  to  operation, 
104 

Diagnosis,  95 
Dysphagia,  94 

Endolaryngeal  removal,  97 

results  of,  98 

indications  for,  98 
Etiology,  87 
Extrinsic,  89 

Frequency,  87 


Glands,  lymphatic,  91 

affection  of,  90 
Gummatous  deposits,  95 

Histology,  91 
Hoarseness,  94 

Impeded  respiration,  94 
Indications  for  operation,  loi 
Infiltration,  93 

Infrathyroid  laryngotomy,  99 
Intrinsic,  89 

Laryngectomy,   partial,    results 
of,  100 

total,  results  of,  loi 
Laryngotomy,  infrathyroid,  99 

suprathyroid,  98 
Lymphatic  vessels,  91 


Index 


107 


Metastasis,  89 

Microscopical    examination     of 
fragments,  95 

Operations  for,  results  of,  loi 

Pain,  94 

Perichondritis,  95 
Primary,  89 
Prognosis,  96 
Pulmonary  disease,  103 

Rapidity,  94 

Results  of  operations,  loi 

Secondary,  89 


Secretion,  94 

Situation,  89 

Stenosis,  94 

Suprathyroid  laryngotomy,  98 

Symptoms,  94 

Thyrotomy,  99 

results  of,  100 
Tracheotomy,  97 
Treatment,  97,  103 

Ulceration,  93 

Vocal  cords,  impaired  mobility 
of,  94 


THE    END 


Bailliere,  Tindall,  &=  Cox,  8,  Henrietta  Street,  Covent  Garden 


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